A099 


cri 


CoUese  of  ^bps^ictanfii  anb  ^urgeonst 
Hibrarp 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/textbookofsurgicOOcolp 


TEXTBOOK 

OF 

SURGICAL  NURSING 


THE   MACMILLAN   COMPANY 

NEW  YORK    •     BOSTON    •    CHICAGO 
DALLAS   •    ATLANTA   •    SAN  FRANCISCO 

MACMILLAN  &  CO..  Limited 

LONDON    •    BOMBAY    ■    CALCUTTA 
MELBOURNE 

THE  MACMILLAN  CO.  OP  CANADA,  Ltd. 

TORONTO 


TEXTBOOK  OF 
SURGICAL    NURSING 


BY 
RALPH    COLP,  A.B.,  M.D. 

INSTRUCTOR     IN    SURGERY,     COLUMBIA    UNIVERSITY,    NEW    YORK  ;     LECTURER 

IN    SURGICAL    NURSING,    PliESBYTEKIAN    HOSPITAL    TRAINING    SCHOOL 

FOR      NURSES,      NEW      YORK  ;       ADJUNCT      VISITING      SURGEON, 

VOLUNTEER  HOSPITAL,  NEW   YORK  ;  CHIEF    OF    SURGICAL 

CLINIC,     BETH     ISRAEL     HOSPITAL,     NEW     YORK; 

FORMERLY    LECTURER    IN    NURSING    AND 

HEALTH,      TEACHERS      COLLEGE, 

COLUMBIA    UNIVERSITY, 

NEW    YORK 


AND 

MANELVA  WYLIE  KELLER,  B.S.,  R.N. 

FORMERLY     CHIEF     OPERATING     ROOM     NURSE,     ST.      LUKE'S 

HOSPITAL,     NEW     YORK,     AND     ANESTHETIST,     ST. 

LUKE'S      HOSPITAL,      NEW      YORK,      AND 

MOBILE        HOSPITAL        NO.        2, 

A.    E.    F.,    FRANCE 


THE  MACMILLAN  COMPANY 
1921 


All  rights  reserved 


PRIA'TED   IN    THE   UNITED   STATES    OF   AMERICA 


COPYDIGHT,     1921, 

By  the   MACMILLAN  COMPANY 


Set  up  and  electrotyped.     Published  June,   1921. 


Press  of 

J.  J.  Little  &  Ives  Company 

New  York,  U.  S.  A. 


DEDICATED 

IN   RESPECTFUL   TRIBUTE 

TO   THE 

COURAGEOUS   AND   DEVOTED    NURSES 

WHO   SACRIFICED    THEIR   LIVES 

TO   THE 

CAUSE   OF    SUFFERING    HUMANITY 

IN   THE   GREAT   WAR 


.0^ 


PREFACE 

The  authors  have  endeavored  to  present  as  accurately  and 
as  simply  as  possible  for  the  pupil  nurse  the  actual  detailed 
nursing  of  the  various  conditions  related  to  things  surgical. 
The  various  procedures  are  based  on  the  technic  employed 
in  hospitals  throughout  the  country,  and  therefore  the  book 
will  be  found  useful  as  a  text  in  training  schools  generally 
without  regard  to  local  conditions.  It  presupposes  a  thorough 
knowledge  of  the  elements  of  practical  nursing.  The  funda- 
mental treatments,  as  a  rule,  have  been  carefully  learned  in  the 
probationary  periods,  but  a  thorough  understanding  of  the 
underlying  principles  of  surgery  and  the  necessary  surgical 
nursing  are  often  wanting. 

While  it  is  true  that  all  orders  are  given  by  the  surgeon,  and 
executed  with  dispatch  and  accuracy  by  the  nurse,  the  time  has 
passed  when  the  nurse  was  a  mere  automaton.  She  must  know 
the  ante-  and  post-operative  care  required  for  all  the  patients 
coming  under  her  supervision.  The  complete  management  of 
an  operating  room,  as  well  as  the  conversion  of  a  private  home 
into  a  suitable  place  for  surgical  procedures,  should  be  thor- 
oughly understood,  and  an  operation  by  name,  be  it  "glos- 
sectomy,"  "thyroidectomy,"  or  ' '  choledochotomy, "  etc., 
should  immediately  summon  to  mind  the  condition  and  the 
technic  involved.  The  nurse  should  be  well  acquainted  with 
the  recent  surgical  developments  of  the  World  War,  such  as 
the  Carrel-Dakin  method  of  M^ound  disinfection,  the  ambrine 
treatment  for  burns,  and  the  suspension  treatment  for  fractures, 
since  her  aid  is  essential  for  their  proper  accomplishment. 

The  chapter  dealing  with  Surgical  Dietetics  has  been  based, 
in  the  main,  on  the  diet  lists  used  by  the  Presbyterian  Hos- 
pital, New  York.  We  are  indebted,  for  the  photomicrographs, 
to  the  Surgical  Department  of  Columbia  University,  and  for 


viii  PREFACE 

some  of  the  pictures  to  the  *' Manual  of  Splints  and  Appliances, 
Medical  Department,  United  States  Army." 

The  authors  -wish  to  express  their  appreciation  and  thanks 
to  Miss  F.  Evelyn  Carling,  Assistant  Superintendent  of  Nurses, 
St.  Luke's  Hospital,  New  York,  for  her  advice  and  many  sug- 
gestions, and  to  Mrs.  Ralph  Colp,  and  Mrs.  Amy  P.  Phillips 
for  their  keen  interest  and  invaluable  assistance  in  the  prep- 
aration of  this  volume. 


INTRODUCTION  AND  HISTORY 

SuRGEEY  is  as  old  as  human  needs.  There  have  always  been 
bleeding  wounds  and  broken  limbs,  and  human  ingenuity  has 
always  endeavored  more  or  less  successfully  to  relieve  the  suf- 
fering so  occasioned.  In  ancient  times,  the  supposedly  super- 
natural secrets  of  the  healing  art  were  zealously  guarded  from 
the  laity,  and  not  till  the  Greek  Hippocrates  in  460  B.C.  wrote 
his  surgical  treatises  did  surgery  pass  from  mysticism  to  sci- 
ence. So  keen  were  the  observations  of  Hippocrates  that  some 
enthusiasts  claim  that  his  two  w^orks  on  fractures  and  dis- 
locations are  in  many  respects  unsurpassed  even  to-day.  And 
until  as  recently  as  four  centuries  ago  very  little  was  added  to 
the  storehouse  of  surgical  knowledge. 

During  the  early  Christian  era  and  the  Middle  Ages,  sur- 
gery was  practised  by  many  different  classes  of  society,  by 
friars  and  barbers,  by  monks  and  nuns,  by  the  famous  Arabian 
court  physicians,  and  by  ladies  of  noble  birth.  The  universi- 
ties from  the  very  beginning  prohibited  research  of  any  kind 
and  demanded  that  every  procedure  be  justified  by  the  author- 
ity of  Galen.  Now  and  then  solitary  thinkers  tried  to  find 
out  things  for  themselves  by  observation  and  reflection.  The 
great  occupation  of  the  majority  of  the  people  was  warfare 
and  much  of  the  little  progress  in  surgical  knowledge  owed 
its  inspiration  to  the  necessities  of  war.  But  even  to  aid  the 
king's  armies  the  new  truths  learned  by  experience  and  ob- 
servation were  discountenanced  by  the  faculties  of  the  uni- 
versities. In  spite  of  this  opposition,  by  the  fifteenth  and  six- 
teenth centuries  there  was  a  widespread  awakening  of  the  free 
scientific  spirit.  It  manifested  itself  in  the  forming  of  groups 
to  study  and  experiment  in  physics,  chemistry,  anatomy  and 
physiology.  Tremendous  progress  was  made  in  all  the  sci- 
ences.    Harvey   discovered   the   circulation   of   the   blood,   the 


X  INTRODUCTION  AND  HISTORY 

mkroscope  came  into  use,  aud  Fahrenheit  invented  the  ther- 
niometer,  "We^-tern  Europe  broke  out  into  a  galaxy  of  names 
that  outshine  the  utmost  scientific  reputations  of  the  best  age 
of  Greece,"  says  II.  G,  Wells;  and  of  these  Vesalius  and  Fal- 
lopius,  the  anatomists,  are  especially  honored  by  surgeons  of 
to-day. 

By  the  eighteenth  century,  private  dissecting  rooms  and  ana- 
tomical laboratories  M'ere  flourishing.  However,  the  surgeons 
themselves  of  this  jieriod  neither  helped  nor  shared  in  this 
great  advancement  of  science.  The  barber-surgeons  were  an 
untutored  lot,  ready  to  make  use  of  a  few  tricks  of  the  trade 
for  practical  gain.  The  task  remained  to  place  the  practice 
of  surgery  on  a  high  plane,  and  this  was  one  of  the  many 
good  deeds  which  make  the  name  of  John  Hunter  shine  out  in 
the  history  of  surgery-.  "More  than  any  other  man  he  helped 
to  make  us  gentlemen,"  a  contemporary  said  of  him.  Through 
the  efforts  of  Dr.  Hunter,  the  already  existing  companies  of 
barber-surgeons  were  forced  to  study  anatomy,  comparative 
anatomy  and  physiology,  and  thus  the  surgical  profession  by 
the  right  of  hard  and  regulated  study  began  to  take  rank  with 
the  high  order  of  scientists.  Public  museums  of  anatomy  and 
physiology  were  founded;  the  method  of  clinical  teaching  was 
adopted;  and  in  the  beginning  of  the  nineteenth  century  the 
day  of  painless  operation  had  come  with  the  discovery  of  an- 
esthesia. 

Still  the  surgeon  was  held  in  disrepute.  The  dark  ages  when 
investigation  w^as  forbidden  were  passed;  all  the  sciences  aided 
the  surgeon;  he  progressed  with  the  great  advance  in  anatomy, 
physiology  and  pathology.  And  yet,  the  hospitals  where  he 
operated  were  considered  houses  of  certain  death.  An  opera- 
tion was  in  truth  a  sad  affair.  No  matter  how  great  the  tech- 
nical skill  of  the  surgeon,  patients,  more  often  than  not,  died 
of  blood  poisoning.  Now  and  then  a  wound  did  heal  wdthout 
the  formation  of  pus,  but  both  spontaneous  and  operative 
wounds  almost  invariably  became  infected,  with  death  as  the 
result.  So  common  was  this,  particularly  in  hospitals,  that 
many  surgeons  feared  to  operate  at  all.  The  term  "hospi- 
talism ' '  was  coined  by  Sir  James  Y.  Simpson,  who  collected  sta- 


INTRODUCTION  AND  HISTORY  xi 

tistics  proving  that  private  patients  were  far  less  liable  to 
succumb  from  operation  than  those  treated  in  hospitals. 

With  the  advent  of  Lister  came  "a  light  that  brightens  more 
and  more  as  the  years  give  us  ever  fuller  knowledge,"  as  Sir 
William  Osier  has  said.  It  was  to  the  researches  of  Pasteur, 
the  great  French  scientist,  that  Lister  owed  his  inspiration. 
One  of  the  first  practical  results  of  Pasteur's  studies  on  fer- 
mentation and  spontaneous  generation  was  a  great  transforma- 
tion in  the  practice  and  results  of  surgery.  It  is  not  too  much 
to  claim  this  as  one  of  the  greatest  boons  ever  conferred  on 
humanity.  Let  us  quote  from  Lister's  paper  on  the  subject 
which  appeared  in  the  London  Lancet,  1867. 

"Turning  now  to  the  question  of  how  the  atmosphere  pro- 
duces decomposition  of  organic  substances,  we  find  that  a  flood 
of  light  has  been  thrown  upon  this  most  important  subject  by 
the  researches  of  Pasteur,  who  has  demonstrated  by  thoroughly 
convincing  evidence  that  it  is  not  to  its  oxygen  or  to  any  of  its 
gaseous  constituents  that  the  air  owes  this  property,  but  to 
minute  particles  suspended  in  it  which  are  the  germs  of  various 
low  forms  of  life  long  since  revealed  by  the  microscope  and  re- 
ga;rded  as  merely  accidental  concomitants  of  putrescence,  but 
now  shown  by  Pasteur  to  be  its  essential  cause,  resolving  the 
complex  organic  compounds  into  substances  of  simpler  chem- 
ical constitution,  just  as  the  yeast  plant  converts  sugar  into 
alcohol  and  carbonic  acid." 

From  Lister's  work  modern  surgery  takes  its  rise  and  the 
whole  subject  of  wound  infection,  not  only  in  relation  to  sur- 
gical diseases  but  also  to  childbed  or  puerperal  fever  now  forms 
one  of  the  most  brilliant  chapters  in  the  history  of  Preventive 
Medicine.  So  great  have  been  the  results  of  Lister's  work  that 
it  is  indeed  almost  difficult  from  our  fortunate  position  of  to-day 
to  glimpse  the  sad  position  of  the  surgeons  of  his  time.  In 
present-day  hospitals  surgical  infection  and  puerperal  fevers 
are  almost  things  of  the  past,  and  for  these  achievements  alone 
the  names  of  Louis  Pasteur  and  Joseph  Lister  will  go  down  to 
posterity  as  among  the  greatest  benefactors  of  humanity. 

Lister's  work  Avas  the  beginning  of  antiseptic  surgery.  Sur- 
geons at  last  learned  to  combat  with  a  strong  antiseptic  the 


xii  IXTRODUCTION  AND  HISTORY 

germs  wiiicli  exist  in  the  air,  the  wound,  the  room,  the  sur- 
geon's hands,  his  instruments.  The  blaek-robed,  professorial- 
looking  surgeon  of  i^arlier  times  was  sueeeeded  by  a  surgeon 
clothed  in  immaeuhite  Avliite.  For  an  operation  in  the  true 
Listeria!!  style,  tlie  part  to  be  operated  on  Avas  first  of  all  e!!- 
veloped  two  hours  before  the  operation  i!i  a  towel  soaked  i!i 
carbolic  acid,  to  destroy  the  germs  prese!it  i!i  the  skin.  In- 
struments a!id  spo!iges  lay  for  a  half  hour  in  a  flat  porcelain 
dish  of  carbolic  acid.  Towels  soaked  in  this  solutio!i  covered 
the  tables  and  bla!ikets  near  the  part  to  be  operated  o!!.  The 
l!a!ids  of  the  snrgeo!is  a!id  !iurses  were  thoroughly  washed  i!i 
the  sa!ne  solution.  The  operation  itself  was  performed  under 
a  cloud  of  carbolized  vapor  fro!ii  a  steam  spray  producer. 
The!i  a  strip  of  oiled  silk,  coated  with  carbolized  dextrin  and 
further  washed  in  carbolic  lotio!i,  Avas  placed  over  the  wound 
a!id  over  this  was  applied  a  double  ply  of  carbolic  soaked  gauze, 
covered  with  eight  layers  of  dry  gauze.  Finally  came  a  thin 
mackintosh  cloth,  a!id  this  whole  apparatus  was  covered  with 
a  gauze  ba!idage.  The  mackintosh  cloth  served  to  prevent  the 
carbolic  acid  from  escaping  and  at  the  same  time  permitted 
the  discharge  from  the  wound  to  spread  through  the  gauze. 
The  vapor  given  off  by  the  carbolic  gauze  shielded  the  "wound 
and  the  surrou!iding  parts  from  septic  co!itamination.  These 
conditions  were  very  strictly  maintained  until  the  wound  was 
healed. 

All  these  cumbersome  and  complicated  measures  may  seem 
a  bit  unnecessary  to  us ;  especially  may  we  sigh  Avhen  we  re- 
flect that  the  use  of  carbolic  acid  made  Lister's  hands  red  and 
raw.  So!ne  surgeons  produced  excellent  results  by  methods  of 
strict  cleanliness  without  following  the  Avhole  Listerian  tech- 
nic.  Gradually,  Lister  himself  gave  up  most  of  these  meas-i 
ures,  much  to  the  advantage  of  the  patient,  for  that  same  car- 
bolic acid  which  so  effectively  destroyed  pathogenic  bacteria  in 
and  about  a  wound,  also  invariably  injured  the  exposed  tissues. 
The  great  achievement  of  Lister  was  not  the  spray  and  gauze 
method  but  the  conclusive  proof  that  cleanliness  is  the  most 
essential  factor  in  successful  operating. 

To  the  antiseptic  surgeon  of  1867  has  succeeded  the  aseptic 


INTRODUCTION  AND  HISTORY  xiii 

surgeon  of  to-day.  The  aseptic  surgeon  uses  steam  and  hot 
water  to  sterilize  all  materials  in  the  operative  procedure,  and 
not  only  does  he  carefully  scrub  his  hands,  but  he  also  renders 
them  absolutely  germ-proof  by  wearing  rubber  gloves  which 
have  been  previously  sterilized  by  boiling  water  and  steam. 
Such  is  the  simple  aseptic  method  which  has  been  gradually 
evolved  from  the  Listerian  antiseptic  system.  The  spray  pro- 
ducer has  almost  passed  into  oblivion  but  the  spirit  of  Lister's 
teachings — scientific  cleanliness — still  guides  the  surgeon's 
work. 

In  the  World  War  aseptic  surgery  proved  of  little  avail,  be- 
cause almost  all  wounds  were  contaminated  and  filled  with  pus. 
The  wound  of  the  battlefield  is  not  similar  to  the  operative 
wound  of  the  civilian  hospital.  Even  with  the  utmost  effi- 
ciency, before  those  wounded  in  modern  warfare  can  be  con- 
veyed to  the  nearest  surgical  station  much  time  will  have 
elapsed  with  ample  opportunity  for  contamination.  To  deal 
with  these  conditions,  the  antiseptic  method  was  revived.  This 
time,  however,  the  strong  carbolic  acid  of  Listerian  fame  was 
replaced  by  an  agent  harmless  to  the  tissues,  the  Carrel-Dakin 
Solution.  This  solution  is  not  merely  one  of  historical  inter- 
est, but  widely  used  by  surgeons  of  to-day  for  a  certain  type  of 
wound,  and  it  will  be  discussed  in  detail  in  Chapter  XIX. 

To-day  the  vision  of  surgery  is  glorious.  The  surgeon  is 
everywhere  recognized  as  an  indispensable  worker  in  the  com- 
munity. The  growth  of  a  highly  competent,  scientifically 
trained  nursing  staff  has  more  than  doubled  the  good  results 
of  his  work.  Nurses  have  indeed  existed  from  earliest  Chris- 
tian times ;  they  have  either  been  gentle,  noble-minded  Sisters 
of  Mercy  in  the  convents,  or  uneducated,  inefficient  maids  in 
hospitals.  Neither  of  these  classes  was  what  could  be  called 
trained  or  educated  according  to  the  present  view  of  what 
training  and  education  should  be  for  a  nurse.  The  first  train- 
ing-school for  nurses  was  established  as  recently  as  1836.  This 
little  school  at  Kaiserswerth,  Germany,  is  the  mother  of  the 
present  system ;  within  its  walls  Florence  Nightingale  acquired 
her  practical  knowledge  of  nursing  in  a  few  months'  time. 
Miss  Nightingale  was  a  woman  of  genius  and  vision.     During 


xiv  INTRODUCTION  AND  HISTORY 

the  Crimean  War  the  London  Times  roused  British  public  opin- 
ion by  its  vivid  account  of  the  terrible  conditions  in  the  mili- 
tary hospitals  of  the  war  zone,  and  Miss  Nightingale  set  out 
for  that  region  with  a  staff  of  trained  nurses  to  superintend 
the  care  for  the  sick  and  wounded.  What  she  actually  accom- 
I)lished  was  of  greater  importance  to  humanity  than  nursing 
individual  soldiers  stricken  in  the  Crimea.  She  applied  the 
principles  of  hygiene  to  hospital  administration  and  brought 
light,  cleanliness  and  order  out  of  indescribable  chaos  and 
misery.  The  "lady  with  the  lamp"  at  Scutari  showed  what 
a  hospital  should  be  and  what  scientific  nursing  should  mean. 
Although  her  work  in  the  Crimea  Avas  done  more  than  a  score 
of  years  before  Lister 's  revolution  in  surgery,  Miss  Nightingale 's 
revolution  in  hospital  building,  administration  and  manage- 
ment was  based  on  the  Listerian  idea  of  scientific  cleanliness. 
And  out  of  her  work  in  the  Crimea  arose  trained  nursing  on  a 
large  scale.  In  1860  the  modern  hospital  school  system  was 
inaugurated  by  her  in  Great  Britain  at  St.  Thomas's  Hospital, 
Loudon,  The  dignity  of  the  nursing  profession  has  thus  been 
raised;  it  has  become  a  calling  for  superior  women,  with  the 
recognition  of  the  need  for  a  rigid  education  and  training  before 
the  nurse  can  call  herself  a  "graduate."  Just  as  surgeons 
were  made  "gentlemen"  by  the  work  of  John  Hunter,  so 
nurses  through  the  efforts  of  Florence  Nightingale  were  made 
"ladies,"  and  their  profession  put  on  a  very  high  plane  of 
social  usefulness. 

In  the  same  decade  that  the  Nightingale  Fund  School  was 
founded  at  St.  Thomas's,  Lister's  great  work  was  given  to  the 
world.  That  is,  the  rise  of  modern  surgery  is  contemporaneous 
with  the  beginning  of  a  careful,  trained  nursing  body.  This 
is  more  than  an  historical  coincidence,  for  since  that  time  the 
increasing  demands  of  medical  and  surgical  knowledge  have, 
well  nigh  revolutionized  the  nursing  craft.  To-day  the  sur- 
geon in  the  operating  room  of  the  hospital,  or  in  the  private 
home  has  come  to  rely  absolutely  on  a  highly  educated  and 
trained  nurse.  To  her  he  leaves  the  preparation  of  supplies,  the 
preparation  of  the  operating  room  and  instruments,  and  the 
preparation  of  the  patient;  she  even  assists  the  surgeon  in  the 


INTRODUCTION  AND  HISTORY  xv 

operation  itself  in  many  ways.  And  finally,  most  of  the  after 
care  of  the  patient  is  left  entirely  to  the  nurse.  It  is  a  great 
need  that  the  nurse  fills,  a  need  that  will  grow  with  her  capac- 
ity to  fill  a  greater  sphere.  She  is  the  Handmaid  of  Surgery 
and  must  live  up  to  that  high  social  calling  by  being  well  pre- 
pared; she  must  be  so  educated  and  trained  that  she  will  not 
be  a  mere  automatic  tool,  but  an  intelligent,  enthusiastic  co- 
worker, filled  with  a  zeal  for  science,  and  giving  her  whole  mind 
and  heart  to  the  work  that  is  before  her — for  only  recently  in 
the  history  of  surgery  is  there  scientific  surgical  nursing.  The 
surgical  nurse  is  a  pioneer ;  the  trail  has  been  blazed ;  but  it  is 
still  a  new  one,  and  she  must  show  what  she  can  do. 


TABLE  OF  CONTENTS 


CHAPTER  PAGE 

Introduction  and  History ix 

I.     Pathology 3 

II.    Shock  and  Hemorrhage 14 

The  treatment  of  shock,  transfusions,  the  treatment  of  hemor- 
rhage. 

III.     Post-Operative  Complications 20 

Nausea,  vomiting,  pernicious  vomiting,  gastric  dilatation, 
tympanites,  auto-intoxication,  post-operative  pneumonia, 
pulmonary  embolism,  urinary  retention,  urinary  suppres- 
sion, phlebitis,  thrombosis,  hemophilia. 

rV.     The  Surgery  and  Surgical   Nursing  op  the   Alimentary 

System 38 

V.     The   Surgery    and    Surgical    Nursing    of    the    Glandular 

System 72 

VI.     The    Surgery    and    Surgical    Nursing    of    the    Nervous 

System 80 

VII.     The    Surgery    and    Surgical     Nursing    of    the    Osseous 

System 87 

VIII.     The  Surgery  and  Surgical  Nursing  of  the  Reproductive 

System 105 

IX.     The  Surgery  and  Surgical  Nursing  of  the  Respiratory 

System 120 

X.     The    Surgery    and    Surgical    Nursing    of    the    Skin    and 

Appendages 130 

XI.     The    Surgery    and    Surgical    Nursing    of    the    Urinary 

System 142 

XII.     Surgical  Dietetics 151 

XIII.     Anesthesia 173 

Preparation  of  the  patient ;  care  of  patient  during  anesthesia ; 
after  care. 

XIV.     Arrangement,     Organization,     and     Equipment     of     the 

Operating  Theatre 193 

The  rooms  and  their  furnishings;  the  personnel;  supplies. 

XV.     Operating  Room  Sterilization 232 

Definitions;  the  agents;  practical  methods. 

XVI.     The  Operating  Room  in  Action 263 

Preparation  of  the  room  for  che  operation ;  preparation  and 
sterilization  of  the  operative  field ;  operative  positions  and 
draping;   the  operation;   after  the  operation. 

xvii 


xviii  TABLE  OF  CONTENTS 

CHAPTER  PAGE 

XVII,     Instrument  Passing 296 

Representative  uiieratiuiis;   drains. 

XYIII.     The  Dressing  of  the  Wound 313 

XIX.     TiJE  Carrel-Dakin  Treatment 321 

What  the  system  is;  history;  equipment;  the  four  processes 
of  the  system;   the  Uakin  sohition, 

XX.  Bandaging 355 

Definitions,  uses  of  bandages,  forms  of  bandages,  materials 
used  for  bandages,  sizes  of  bandages,  principles  of  bandag- 
ing, modes  of  applying  the  roller  bandage,  the  applica- 
tion of  bandages  to  the  various  parts  of  the  body,  mis- 
cellaneous special  bandages,  the  fastening  of  the  bandage, 
miscellaneous  bandaging  rules,  the  removal  of  roller 
bandages. 

XXI.  Operations  in  the  Home 399 

The  steps  in  the  preparation  and  management,  improvised 
operative  positions. 

Appendix 415 

Solutions;  weights  and  measures;  equivalent  thermometer 
scales;  abbreviations  and  symbols. 

Index        ...       o       .......       .     437 


LIST  OF  ILLUSTRATIONS 


FIG. 


PAGK 


1.  Microscopic  drawing  of  an  incised  wound  twenty-four  hours  old  5 

2.  Microscopic  drawing  illustrating  the  growth  of  fibroblasts  along 

the  fibrin  of  the  blood  clot 6 

3.  Microscopic  drawing  of  granulation  tissue 7 

4.  Microscopic  drawing  of  an  infected  wound     ....        8  and  9 

5.  Microscopic  drawing  of  a  deep  abscess 11 

6.  Types   of    intestinal    anastomoses      .        .        .        .       '.        •        •  5* 

7.  Colostomy    before    being    incised       .        .        .        .        •        .        .  61 

8.  Colostomy  bag 61 

9.  Tube  "en  cliemise"      .        .        . 64 

10.  Methods  of  applying  traction 95 

11.  Traction   leg   splint .96  and  97 

12.  Traction  arm  splints 99 

13.  Jones  wrist  split 100 

14.  Lane   plate 101 

15.  Wyeth  pins 103 

16.  Tracheotomy    tube 123 

17.  Brewer    empyema    tube 127 

18.  An  easy  and  safe  method  of  lifting  a  helpless  patient      .        .  181 

19.  Eestraining  sheet  for  patients  recovering  from  an  anesthetic     .  183 

20.  Suitable  instruments   for  grasping   the   tongue      ....  185 

21.  Mouth  gags ' 186 

22.  Two  of  the  more  elaborate  types  of  operating  table     .        .        .197 

23.  Two  varieties  of  instrument  table 199 

24.  Adjustable   instrument   table 199 

25.  Wheel  stretcher 200 

26.  Carrying    stretcher 200 

27.  Stretcher  suitable  for  carrying  patients  up  and  down  stairways  200 

28.  Seat  for  the  anesthetist  or  surgeon 201 

29.  Bench  for  the  surgeon  to  stand  upon  when  the  operating  table 

can  not  be   adjusted  suitably  in  height 201 

30.  Hand  light 202 

31.  Dressing  drum  with  pedal  opening  standard 202 

32.  Hot  towel  drum  with  pedal  opening  standard  and  electrically 

equipped  steaming  device 203 

33.  Instrument  sterilizer 203 

34.  Utensil  sterilizer 204 

xix 


XX  LIST  OF  ILLUSTRATIONS 

FIO.  PAOH 

35.  Hot  and  cold  water  sterilizers 205 

36.  Wash  basins 207 

37.  Two  types  of  arm  basin 208 

38.  Amputation    retractors 214 

39.  Muslin   apron 215 

40.  Operating  caps 216 

41.  Culture  tubes 217 

42.  Glove  cover 219 

43.  Two   types  of  hip   or  pelvic   rest 220 

44.  Two  types  of  irrigator  stand 221 

45.  Face  masks 222 

46.  Abdominal  pads 224 

47.  Laparotomy    sheet 227 

48.  Lithotomy  towel     .        .        . .230 

49.  Steam  pressure  dressing  sterilizer 238 

50.  Hot  air  sterilizer 242 

51.  The  Mayo  soldering  iron  cautery 243 

52.  Electric  cautery 243 

53.  The  Paquelin  cautery 244 

54.  Needle  book 253 

55.  Method  of  rolling  a  catgut  suture  or  ligature 255 

56.  Factory  prepared  catgut  in  hermetically  sealed  glass  tube        .  261 

57.  Dorsal   position 267 

58.  Method  of  fastening  the  arms  at  the  patient's  side    .        .        .  268 

59.  Method  of  fastening  the  arms  on  the  chest 269 

60.  Laparotomy  sheet  in  place  for  an  abdominal  operation      .        .  269 

61.  Draping  for  the  dorsal  position  with  two  sheets  and  four  towels  270 

62.  Two  types  of  towel  clamps 270 

63.  Trendelenburg   position 271 

64.  Shoulder  guard  for  keeping  the  patient  in  place  in  the  Trendelen- 

burg position 271 

65.  Gall   bladder   position    (with    table   rest)         .        .        .        .        .272 

66.  Gall  bladder  position   (with  broken  table) 273 

67.  Kidney  position 274 

68.  Prone  position 275 

69.  Latero-prone  position 276 

70.  Eeversed   Trendelenburg  position 276 

71.  Sims  position,  showing  the  use  of  one  sheet  for  draping     .        .  277 

72.  Lithotomy  position,  showing  the  use  of  the  table  stirrups     .        .  277 

73.  Draping  with  a  sheet  and  towels  in  the  lithotomy  position     .        .  278 

74.  Draping    with    the    lithotomy    towel     and    stockings    for    the 

lithotomy  position 279 

75.  Breast   position 280 

76.  Method  of  draping  the  hand  and  forearm  for  the  breast  opera- 

tion         281 


LIST  OF  ILLUSTRATIONS 


XXI 


U\) 


when  the 


FIO. 

77.  Draping  for   lironst    position 

78.  Detachable  arm   Ijofud  siip])lic(l  wii.li  tli 

79.  Simple  long  narrow  boai-d  which  may  be  fitted  to  any  table  as 

an  arm  board 

80.  Use  of  stirrups  for  operations  upon  the  leg 

81.  Draping    for    leg    operations 

82.  Draping  for  a  face  case      .... 

83.  Arrangement  of  patient  in  the  prone  position  on  a  special  hear 

rest  for  operations  upon  the  back  of  the  head  or  neck 

84.  Folded  towel  clamped  about  the  face  to  protect  the  operative 

field  from  the  inhaler  in  face,  neck,  or  skull  operations 

85.  The  Kocher   guard   adjusted   and   draped   so   as   to   isolate   the 

anesthetist  in  operations  upon  the  neck 

86.  Portable  dressing  stand 

87.  Diagram  of  the  arrangement  of  the  instrument  stand 

type  shown  in  Fig.  24,  page  199  is  used     . 

88.  Intestinal    and   stomach    clamps         .... 

89.  Drains . 

90.  Portable  metal  dressing  box 

91.  Portable  electric  instrument  sterilizer 

92.  Dressing  carriage  for  use  in  the  hospital  ward 

93.  Adhesive  plaster  and  tape  device  for  holding  dressings  in  place 

and  allowing  their  removal  without  the  disturbance  of  the 
plaster  

94.  Dressing  forceps  for  use  in  dressing  the  Carrel-Dakin  wound     . 
-95.     The  rubber  delivery  tubes 

96.  Reservoirs  for  the  Dakin  solution 

97.  Glass  syringes  for  administering  the  Dakin  solution     . 

98.  Stopcocks  for  use  on  the  supply  tubing  in  the  reservoir  method 

of  administering  the  Dakin  solution 

99.  Glass  connecting  and  distributing  tubes 

100.  Glass   dropper   tube   for   use   oii   the   main   supply   tube   in   the 

reservoir    continuous    method 

101.  The  way  to  perforate  the  wound  tube 

102.  The  way  to  lay  the  vaseline  gauze  strips  around  the  margin  of 

the  wound   

103.  Four   positions   of   wounds  with    the   appropriate   wound   tubes 

in   them 

104.  Diagram  of  possible  ways  of  making  exits  through  the   gauze 

and  cotton  pad  for  the  wound  tubes  so  that  they  need  not 
lie  on  the  skin  surface,  and  will  remain  where  they  were 
placed  when  the  wound  was  dressed 

105.  Arrangement    of    the   apparatus   for    the    reservoir    method    of 

instillation 

106.  Suggested  ways  of  branching  the  main  supply  tube  so  that  it 

can  feed  the  tubes  of  more  than  one  wound,  or  widely  scat- 
tered and  variously  grouped  tubes  in  the  same  wound     . 


PA  OK 

281 

282 


283 

284 
285 
285 


286 

287 

289 
290 

299 
303 
311 
314 
315 
316 

317 
324 
325 
326 
326 

327 
327 

328 
329 

336 

337 


339 
340 

341 


xxii  LIST  OF  ILLUSTRATIONS 

FIG.  PAGE 

107.     Arrangeinciit  of  the  screw  stopcock  and  the  glass  dropper  tube 
on  the  main  supply  tube  for  the  reservoir  continuous  method 

of  instiilation .342 

lOS.     Method    of    connecting    inaccessible    wound    tubes    to    a    single 

supply  tube  for   the   syringe   method   of   instillation      .        .  343 

109.  Dr.  Carrel's  bacteriological  chart 346 

110.  The   roller   bandage 356 

111.  Two  methods  of  rolling  a  bandage  by  hand 357 

112.  The  triangular  bandage,  or  sling 358 

113.  Many-tailed  bandages 359 

114.  Method   of   making  plaster  of  Paris  bandages      ....  361 

115.  The   way   to    grasp    the    roller   bandage    preparatory   to    apply- 

ing it 366 

116.  The  way  to  begin  the  application  of  the  roller  bandage      .        .  367 

117.  The  circular  mode  of  bandaging — the  usual  anchorage  for  the 

applied  roller  bandage 367 

118.  The  spiral  mode  of  bandaging 368 

119.  The  wrong  mode  for  the  part  (the  spiral  mode  for  a  conically- 

shaped  part) 369 

120.  The  way  to  make  a  reverse 369 

121.  The  figure-of-8  mode  of  bandaging 370 

122.  The  recurrent  mode  of  bandaging 371 

123.  Completed  recurrent  bandage 372 

124.  Spiral    bandage   of    the    finger    anchored   to    the    wrist   with    a 

figure-of-8  and  a  circular  turn 374 

125.  The  thum.b  spiea 374 

126.  Complete  bandage  for  the  hand  and  arm 375 

127.  Eeverse   figure-of-8    bandage 375 

128.  Method    for    securing    better    anchorage    of    a    bandage    on    a 

tapering  part 376 

129.  Heel   bandage 377 

130.  Complete  bandage  for  the  foot  and  leg 378 

131.  The  eye  bandage 379 

182.     Double  eye  bandage 380 

133.  The  ear  bandage 380 

134.  The  Barton  bandage 381 

135.  Two  methods  of  bandaging  the  cheek,  temple,  or  chin      .        .  382 

136.  Double   roller   bandage    for    the    application    of    the    recurrent 

bandage 383 

137.  The  way  to  use  the  double  roller  bandage 383 

138.  The  spica  bandage  of  the  shoulder 384 

139.  The  shoulder  spica  bandage  varied  to  cover  the  axillary  region  385 

140.  The  Velpeau  bandage 385 

141.  The  breast  bandage 386 

142.  The    double   breast   bandage 386 

143.  The  hip   spica  bandage 387 


LIST  OF  ILLUSTRATIONS  xxiii 

FIG.  PAGE 

144.  Various  applications  of  the  triangular  bandage     ....  388 

145.  Various  applications  of  the  many-tailed  bandages  ....  389 

146.  Methods  of   fastening  the  roller   bandage 395 

147.  Bandage  scissors 397 

148.  Instruments  for  the  removal  of  plaster  of  Paris  bandages      .  397 

149.  Improvised  cap  and  gown 401 

150.  Ordinary  chair  adapted  for  improvisation  of  the  Trendelenburg 

position 411 

151.  Lithotomy  crutches,  or  leg  holders,  for  supporting  the  legs  in 

the  lithotomy  position 412 

152.  Method  of  improvising  a  lithotomy  crutch 412 

153.  Improvised    Kelly   pad 413 


TEXTBOOK 

OF 

SURGICAL  NURSING 


CHAPTER  I 

PATHOLOGY 

The  surgical  field  may  be  divided  into  those  conditions  which 
are  due  to  inflammation,  injuries,  congenital  deformities,  and 
new  growths.  Into  these  arbitrary  four  great  divisions  all 
modern  surgical  intervention  falls.  And  since  all  surgical  in- 
tervention is  to  a  greater  or  lesser  degree  supplemented  by 
surgical  nursing,  a  thorough  and  intelligent  understanding  of 
the  underlying  pathological  conditions  is  essential.  Perhaps 
the  most  common  field  is  that  of  inflammation. 

Inflammation. — Inflammation,  according  to  Grawitz,  may  be 
said  to  be  the  reaction  of  irritated  damaged  tissues  which  still 
retain  vitality.  The  damaging  element  may  be  one  of  several; 
it  may  be  physical,  such  as  a  cut  from  a  knife,  a  bruise  from 
a  stone,  or  a  contusion  from  a  flying  timber.  It  may  be  chem- 
ical, such  as  a  burn  with  acid,  such  as  nitric,  or  from  caustic 
alkali.  It  may  be  electrical,  resulting  from  touching  a  "live" 
wire;  or  thermal,  such  as  a  burn  from  fire,  or  a  frost  bite  from 
the  cold;  or  it  may  be  bacteriological.  The  last  mentioned  is 
especially  important  for  it  results  in  wound  infection.  These 
five  agents  then  are  the  exciting  factors  of  an  inflammatory 
reaction;  they  have  in  some  way  injured  or  destroyed  the  unit 
structure  of  the  body,  the  cell,  and  in  order  to  carry  ofi^  the 
dead  and  dying  cells,  to  replace  them,  and  rebuild  the  damage 
done,  the  process  of  inflammation  must  ensue. 

What  is  the  process  of  inflammation?  The  following,  in  a 
brief  way,  will  illustrate  what  happens  grossly,  and  what  oc- 
curs if  the  process  were  to  be  studied  underneath  the  mi- 
croscope : 

If  a  finger  is  cut,  it  bleeds.  The  amount  of  blood  lost  is 
dependent  upon  the  size  of  the  vessel  cut.  In  time,  due  to 
clotting,  the  bleeding  ceases  and  within  a  few  hours  the  sur- 

3 


4  TEXTBOOK  OF  SURGICAL  NURSING 

rounding^  skin  may  become  red,  perhaps  slightly  sAvollen,  and 
if  it  is  carefully  observed  as  to  temperature,  it  might  be  some- 
what warmer  than  the  adjacent  skin.  Tlie  wound  is  said  to  be 
inflamed.  If  this  process  were  examined  in  sections  beneath 
a  microscope,  a  very  interesting  and  thoroughly  instructive  pic- 
ture would  be  seen,  depending  upon  the  time  when  the  section 
was  taken.  Within  a  short  period  after  the  original  injury, 
there  would  be  along  the  line  of  the  original  incision  a  clot  of 
blood,  and  adjacent  to  it  some  dead  cells.  (Fig.  1.)  Already, 
the  products  of  these  dead  cells  would  have  stimulated  a  greater 
blood  flow  to  the  part,  resulting  in  a  dilatation  of  blood  vessels 
and  capillaries,  and  an  infiltration  of  the  tissues  with  white 
blood  cells,  red  blood  cells,  and  serum.  Naturally,  it  is  this 
that  makes  the  part  swollen,  red  and  warm.  And  as  these  in- 
flammatory products  cause  an  increased  pressure  on  the  nerves 
the  wound  will  become  painful  in  direct  proportion  to  the  exu- 
dation. It  has  already  been  noted  that  cells  have  been  de- 
stroyed. Dead  tissue  is  of  no  use  to  the  organism.  It  must 
be  removed,  and  the  white  blood  cells  carry  off  the  destroyed 
tissue.  It  is  a  known  fact  that  when  cells  are  injured,  some 
which  were  but  slightly  traumatized  are  actually  stimulated  to 
growth,  and  these  cells  (fibroblasts)  immediately  begin  to  re- 
produce and  grow  into  the  blood  clot  along  the  fibrin  strands 
(Fig.  2)  in  an  attempt  to  bridge  in  the  gap  caused  by  the  de- 
struction of  the  cells  killed  by  the  knife.  In  small  wounds  this 
is  barely  visible  to  the  naked  eye,  but  in  wounds  in  which  a 
definite  area  of  tissue  has  been  destroyed,  or  wounds  with  defi- 
nite loss  of  substance,  this  new  growth  of  cells  together  with 
a  new  growth  of  blood  vessels  is  known  as  granulation  tissue. 
(Fig.  3.)  Wounds  which  are  sutured  and  clean  heal  with  the 
minimum  amount  of  granulation  tissue  and  simulate  small 
cuts  of  the  finger.  This  is  spoken  of  as  healing  by  primary  in- 
tention. Wounds  in  which  there  is  a  loss  of  tissue  from  one 
cause  or  another  heal  by  secondary  intention,  filling  in  the  space 
with  granulation  tissue.  This  is  the  process  of  healing  which 
takes  place  in  every  wound.  It  is  fundamentally  the  same  in 
all  clean  wounds,  whether  a  cut  of  the  finger,  the  healing  of  a 
cyst  enucleation,  or  an  incision  of  the  abdomen  as  a  laparotomy. 


PATHOLOGY 


-U^a'-     '5!'. 


'  •-■  ^-   '^,-  /i<'S 


'■ '-'v.'';  .'■^;'\ :  V-'i.^; ;v- , \\ 


,>", ;-'  • 


^■■7-m 


- B 

C 

A 


'iS^L  -----""=    C> 


Fig.  1. — Microscopic  Drawing  of  Incised  Wound  24  Hours  Old.  A, 
line  of  incision;  B,  blood  clot;  C,  cellular  infiltration;  T),  relative  dilatation 
of  blood  vessels.  Published  by  permission  of  the  Department  of  Surgery, 
Columbia  University. 


TEXTBOOK  OF  SURGICAL  NURSING 


A 


-B 


^'Kic 


Fig.  2. — Microscopic  Drawing  Illustrating  the  Growth  op  Fibro- 
blasts Along  Fibrin  Strands  of  the  Blood  Clot.  A,  fibrin  strands;  B, 
fibroblasts.  Published  by  permission  of  the  Department  of  Surgery,  Colum- 
bia University. 


PATHOLOGY  7 

The  process  is  slightly  different,  however,  when  the  wound  be- 
comes contaminated  by  bacteria  of  the  pathological  variety. 
In  a  clean  wound  the  minimum  amount  of  damage  is  done 


^T-  B 


*  ••• 


"*^'' 


-  -,-A 


Fig.  3. — Microscopic  Drawing  of  Granulation  Tissue.  A,  fibroblasts; 
B,  newly  formed  blood  vessels.  Published  by  permission  of  the  Department 
of  Surgery,  Columbia  University. 

because  the  only  cells  destroyed  are  those  which  have  been 
killed  by  the  knife  of  the  surgeon.  But  if  this  knife  were  not 
properly  sterilized  and  were  laden  with  bacteria,  the  result 
would  be  an  infected  wound  (Fig.  4),  and  the  outcome  would 


TEXTBOOK  OF  SURGICAL  NURSING 


< 

I 

I 


I 


/•iMtA; 


H 


^■;.;- 


J 


'ATHOLOGY 


o 


o 
\ 


1 


F^r^r^f      ^ 


Hi?:.- 


.-Q 


<>^ 


p 


ti 


■^' 


SH> 


^ 
$? 


'C3 


««••■■*      c 


.;,;* 


»      '         ^^  '  ■  •••      'I't    ■•  • 


i5    -.^     ''vv:^'    V.      '" 


■•-.••"     .'■^ 


•     i 


i»J 


'vf*.?'-. 


J  •       ^ . ' 


*»/"       "         (.'■'.     i"  *  .       ,5.      '■?!'i''>';'' ■'^''^■ 


'> 


^^ 


Pq 

fi 

&< 

o 

C5 

f/i 

O 

•  r-l 

'^ 

c 

;> 

Qj 

< 

Ph 

K 

t^ 

«^ 

vJ 

rg 

< 

^ 

H 

Oi 

W 

pj^ 

« 

-Q 
3 

o 

CM 

Ph 

<■■> 

m 

10  TEXTBOOK  OF  SURGICAL  NURSING 

be  dependent  upon  the  resistance  of  the  individual  infected, 
and  the  severity  of  the  infecting  organisms.  These  bacteria 
destroy  cells  in  the  same  Ava}'  as  a  knife.  And,  because  of  their 
irritating  properties,  and  their  attempts  to  invade  and  destroy 
the  body,  Nature  summons  the  white  blood  cells  (phagocytes) 
(called  by  Metchnikoff  the  "policemen  of  the  blood")  to  arrest 
the  onslaughts  of  tlie  invading  foes.  These  ■white  blood  cells 
attempt  to  destroy  bacteria.  If  they  are  successful,  the  bac- 
teria remain  local  in  position,  an  abscess  is  formed  (Fig.  5) 
and  the  evidences  of  the  combat  are  found  by  the  appearance  of 
pus  in  the  wound.  Pus  is  composed  of  living  and  dead  bac- 
teria, living  and  dead  white  blood  cells.  Naturally,  in  such  a 
process,  more  tissue  will  be  destroyed  than  in  a  clean  wound. 

A  wound  in  which  there  is  pus  is  spoken  of  as  a  suppurating 
wound ,  and  the  process  is  known  as  suppuration.  When  tissue 
has  been  destroyed  by  the  bacteria  and  the  individual  has  been 
fortunate  enough  to  cause  the  process  to  remain  localized,  the 
dead  tissue  will  fall  off  from  the  living;  the  "line  formed  be- 
tween the  living  and  dead  tissue  is  called  a  line  of  demarcation. 
This  dead  tissue  is  spoken  of  as  slough  and  very  often  it  may 
be  seen  lying  in  a  wound  as  strands  of  yellow  greenish  debris. 
In  those  instances  where  the  amount  of  tissue,  for  one  reason 
or  another,  is  as  large  as  a  toe  or  an  entire  extremity  the  process 
is  known  as  gangrene  or  mortification. 

If  the  individual  through  some  constitutional  inferiority  has 
been  unable  to  localize  the  bacteria,  their  poisons  may  be  ab- 
sorbed into  the  blood  vessels  directly.  The  patient  then  be- 
comes toxic,  and  the  condition  is  known  as  toxemia.  If  not  only 
the  toxins  of  the  bacteria,  but  the  actual  bacteria  themselves 
are  absorbed,  a  sepsis,  septicemia,  or  bacteremia  results.  The 
laity  call  this  "blood  poisoning." 

If  the  pus  itself,  or  collections  of  bacteria,  should  localize  in 
different  parts  of  the  body  and  form  smaller  or  secondary  ab- 
scesses, either  in  the  skin  or  other  organs,  the  condition  is 
known  as  pyemia.  Sepsis  and  pyemia  are  indeed  serious  com- 
plications, for  they  often  spell  death  to  the  patient.  If  they 
follow  in  the  path  of  clean  operations  they  are  due  to  care- 
lessness on  the  part  of  the  surgeon  or  the  nurse.     They  are  a 


PATHOLOGY 


11 


CP 
I 

\ 
\ 
\ 

\ 


< 

I 


;:,|, 
^^'-.1^" 
^"H- 


1--^ 
\-,^' 


■mm. 


t>7i: 


•  :  .  .  -J?a»f.-.jv 


•SI;:: 


' 

m^:. 

■•y 

M 

■f*:?... 


'^^•Ji^y*M€.;s^ 


t 


.;:> 


v:>    i^ 


« 
■>  5 

sa 

to 

o    '^ 
03    P 

pC    OX) 


ft 

fi 

<D 

< 

+j 

fc 

«H 

C 

o 

o 

Pi 

g 

o 

^ 

03 

<; 

c 

Ph 

u 

Pu, 

o 

o 
w 
o 

2 

12  TEXTBOOK  OF  SURGICAL  NURSING 

blot  on  the  scalpel  of  aseptic  surgery.  It  means  that  certain 
bacteria  entered  the  wound  either  before,  during,  or  after  op- 
eration. The  bacteria  which  cause  wound  infections  are  nu- 
merous arid  varied.  A  classification  of  these  organisms  is  here- 
with given : 

Bacteria  are  of  two  classes : — saprophytes,  those  which  live 
on  dead  organic  matter,  and  parasites,  which  derive  their  nour- 
ishment from  living  bodies.  The  latter  class  produce  the  patlio- 
genic  or  disease  bacteria :  these  are  either  cocci  or  bacilli.  The 
various  common  cocci  may  be  divided  into  staphylococci,  strep- 
tococci, pneumococci,  meningococci,  gonococci ;  the  bacilli,  into 
the  bacillus  coli  communis,  bacillus  typhosus,  bacillus  para- 
typhosus  and  bacillus  pyoeyaneus.  These  are  the  germs  which  are 
concerned  in  acute  inflammation.  There  are  others  which  cause 
chronic  inflammations,  the  most  important  of  which  are  the 
tubercle  bacillus  and  the  spirochaete  of  syphilis.  Then  there 
are  those  rarer  forms  of  inflammation  which  are  due  to  the  ba- 
cillus of  anthrax,  of  glanders,  and  those  due  to  the  fungi  group, 
such  as  actinomycosis.  The  pathological  process  of  all  of  these 
is  essentially  the  same ;  it  is  simply  a  question  of  degree  and  in- 
tensity ;  it  is  dependent  upon  the  virulence  of  the  organism  caus- 
ing the  infection,  and  the  general  resistive  powers  of  the  pa- 
tient infected. 

How  do  bacteria  enter  the  body?  They  may  enter  through 
the  hrohen  skin  giving  rise  to  local  inflammation  with  destruc- 
tion of  tissue  and  abscess  formation.  In  addition  they  may 
gain  access  to  the  lymphatics  draining  the  infected  area  causing 
lymphangitis,  and  often  the  nodes  becoming  tender,  hard,  and 
swollen  (lymphadenitis).  Or  the  bacteria  may  enter  the  blood 
stream  directly,  resulting  in  septicemia  or  pyemia. 

Inhalation  is  the  means  by  which  the  pathogenic  bacteria 
enter  the  trachea  and  lungs  causing  the  majority  of  respiratory 
diseases.  By  ingestion  of  food  and  drink,  the  germs  may  enter 
the  tonsils  or  the  alimentary  canal.  Another  portal  of  entry 
in  females  is  through  the  Fallopian  tuhes  directly  into  the  peri- 
toneal cavity  causing  peritonitis  with  its  various  complications. 

If  the  body  is  in  good  health  and  properly  nourished,  all 
these  portals  are  safely  guarded,  but  if  the  individual  is  weak- 


PATHOLOGY  13 

ened  and  the  various  protective  mechanisms  are  at  fault,  dis- 
ease readily  ensues. 

Injuries. — Conditions  of  injury  may  be  caused  by  the  vari- 
ous factors  already  mentioned.  The  extent  of  the  injury  will 
depend  upon  whether  the  bony  skeleton  or  the  soft  parts  are 
involved,  whether  the  solid  organs,  such  as  the  liver  or  kidney, 
are  torn,  or  the  hollow  viscera,  such  as  the  stomach  and  in- 
testines, are  perforated  or  ruptured. 

Deformities. — These  may  be  divided  into  two  big  classes : 
those  a  patient  is  born  with,  and  those  which  a  patient  acquires 
during  life.  Among  some  of  the  congenital  deformities  may 
be  mentioned  spina  bifida,  a  condition  in  which  part  of  the 
bony  portion  of  the  spinal  canal  is  missing,  harelip,  cleft  pal- 
ate, horseshoe  kidney,  six  fingers,  an  extra  arm,  or  the  fusion 
of  two  individuals  as  in  the  case  of  the  Siamese  twins.  Ac- 
quired deformities  may  be  the  results  of  injuries  which  have 
been  improperly  treated,  such  as  a  poor  reduction  of  a  fracture, 
or  from  paralysis  of  muscles  due  to  nerve  injuries  which  cause 
such  conditions  as  drop   wrist   or   drop   foot. 

New  Growths. — New  growths,  neoplasms,  or  tumors,  may 
be  defined  ''as  growths,  non-inflammatory  in  character,  aris- 
ing from  pre-existing  tissue  but  independent  of  the  normal 
rate  or  laws  of  growth  of  such  tissue,  subserving  no  physiolog- 
ical function."  They  may  be  classified  as  benign  and  malig- 
nant. Benign  growths,  as  a  rule,  are  localized;  they  may  be 
excised  without  danger  of  recurring,  and  they  do  not  spread 
to  other  parts  of  the  organism  and  start  new  tumor  formations. 
Examples  of  these  are  fibromas,  lipomas,  and  cysts.  They 
rarely  endanger  the  life  of  the  individual.  Malignant  growths 
are  those  which  are  not  localized,  which  infiltrate  tissues  and 
which  spread  to  various  parts  of  the  body  (metastasize).  They 
are  the  cancers  and  the  sarcomas.  Surgery  attempts  to  remove 
these  with  the  knife.  And  those  cells  which  have  escaped  the 
knife  will  start  foci  for  the  regeneration  of  new  tumor  tissue 
unless  they  are  killed  by  the  destructive  action  of  subsequent 
radium  and  X-ray  treatment. 


CHAPTER  II 
SHOCK    AND    HEMORRHAGE 

Shock. — This  is  one  of  the  most  serious  conditions  with 
which  the  surgeon  and  the  nurse  have  to  cope.  It  may  result 
from  several  circumstances.  It  may  be  associated  directly  with 
severe  injuries,  may  occur  during  the  course  of  an  operation, 
or  follow  in  its  path.  As  to  the  etiology  of  shock  there  are 
many  theories,  but  its  exact  mechanism  does  not  concern  us 
here.  Shock  is  characterized  by  a  rapid,  thready  pulse,  a 
pinched,  drawn  face,  sweating,  rapid,  shallow  respirations,  and 
a  persistently  low  blood  pressure.  Shock  may  be  associated 
with  hemorrhage,  but  there  is  no  severe  hemorrhage  without 
shock. 

Prophylactic  Treatment  of  Shock. — There  are  several  fac- 
tors which  aid  in  the  prophylactic  treatment  of  shock.  To 
begin  with,  the  patient  should  be  kept  in  a  happy  and  cheerful 
frame  of  mind.  He  should  have  a  good  night's  rest  before  his 
operation  and  his  tissues  should  be  well  supplied  with  water. 
This  latter  can  be  easily  accomplished  by  encouraging  the 
drinking  of  fluids  in  copious  amounts.  Of  course,  two  hours 
before  operation  no  more  water  should  be  permitted.  Dur- 
ing his  transport  to  the  operating  room  the  patient  should  be 
warmly  clad  and  when  he  is  placed  upon  the  table  he  should 
be  covered  with  blankets. 

Of  prime  importance  also  is  the  technic  of  the  operation.  As 
little  as  possible  of  the  abdominal  contents  should  be  exposed, 
and  the  exposed  parts  should  be  protected  with  moist,  hot 
saline  pads.  The  tissues  should  be  handled  gently,  the  hemos- 
tasis  should  be  perfect,  and  the  operation  should  be  performed 
with  as  much  speed  as  is  consistent  with  safety.  The  patient 
should  be  kept  under  deep  surgical  anesthesia,  the  choice  of 

14 


SHOCK  AND  HEMORRHAGE  15 

the  anesthetic  being  dependent  upon  the  condition  of  the  pa- 
tient. 

After  operation  it  is  customary  to  administer  morphine  hypo- 
dermically  so  that  the  pain  which  might  arise  will  not  reflexly 
cause  a  general  depression  of  the  nervous  system,  resulting  in 
shock. 

Treatment  of  Shock. — When  a  condition  of  shock  is  evident, 
it  must  be  treated  energetically.  The  patient  should  be  placed 
flat  upon  the  bed  and  covered  with  warm  blankets;  if  neces- 
sary, hot  water  bags  and  electric  pads  may  be  employed  to  rap- 
idly supply  additional  heat.  Inasmuch  as  the  patient  is  un- 
conscious it  is  highly  important  to  carefully  guard  against 
burns  from  the  electric  heating  pad,  or  a  too  hot  w^ater  bag. 
The  foot  of  the  bed  is  raised  by  means  of  shock  blocks,  so  that 
the  head  is  at  a  lower  level  than  the  feet.  Shock  blocks  come 
in  various  sizes:  low,  medium,  and  high.  The  medium  ones 
are  generally  sufficient. 

Stimulants. — Morphine  is  one  of  the  best  stimulants  and 
is  administered  in  quarter  grain  doses  with  1/150  atropine  sul- 
phate. Fluid  is  then  given  by  infusion  in  the  form  of  normal 
saline  at  105  degrees  F.,  and  to  this,  occasionally,  is  added  30 
minims  of  adrenalin  hydrochloride,  1-1000  solution.  If  the 
shock  is  not  so  severe,  fluid  by  hypodermoclysis  or  Murphy  drip 
may  be  sufficient. 

Transfusions. — Since  hemorrhage  may  be  partially  responsi- 
ble for  shock,  the  imperative  need  often  is  to  supply  the  blood 
which  has  been  lost.  Blood  transfusions  no  longer  present  the 
obstacles  which  they  formerly  did,  for  the  long  tedious  sur- 
gical methods  of  arteriovenous  anastomosis  have  been  prac- 
tically replaced  by  the  use  of  the  syringe  and  its  modifications. 

Grouping  for  Transfusions. — Before  any  transfusion  is 
given,  it  is  always  necessary  to  ascertain  the  blood  group  of  the 
patient  and  of  the  "donor,"  because  if  the  bloods  of  different 
groups  are  mixed  together  the  red  blood  cells  are  destroyed  and 
the  patient  is  liable  to  suffer  a  very  severe  reaction,  and  derive 
no  benefit  from  the  treatment.  Human  bloods  are  divided  into 
four  groups.  Of  these  the  largest  are  groups  two  and  four  which 
together  constitute  about  eighty-three  per  cent,  of  all  individuals. 


16  TEXTBOOK  OF  SURGICAL  NURSING 

lu  selecting  a  "donor,"  it  is  very  important  that  he  be  in  good 
physical  health,  and  that  his  blood  be  free  of  syphilis  as  evi- 
denced by  a  negative  Wassermann  reaction. 

Transfusions  may  be  given  by  one  of  three  methods, — the 
direct  arteriovenous  method ;  the  indirect,  as  represented  by 
the  syringe  method ;  and  the  one  in  which  sodium  citrate  is 
used.  The  anastomosis  of  an  artery  of  a  donor  to  a  vein  of  the 
recipient  is  no  longer  done,  because  this  rather  cumbersome 
method  (which  was  rarely  very  successful)  has  been  replaced  by 
the  other  two  types,  which  are  more  efficient,  certainly  easier  of 
operation,  and  less  trying  both  to  patient  and  donor.  The 
syringe  method  first  used  by  Lindenian  employs  glass  record 
syringes  w^hich  draw  the  blood  from  the  vein  of  the  donor; 
the  freshly  drawn  blood  is  then  immediately  injected  through  a 
needle  into  the  vein  of  the  recipient.  The  great  disadvantage 
is  the  fact  that  the  blood  is  apt  to  clot  in  the  needles  of  the 
syringes  in  spite  of  the  fact  that  these  instruments  may  be 
flushed  with  saline  during  the  procedure  as  is  done  in  the  Unger 
method.  To  overcome  this  obstacle,  a  method  frequently  used 
at  the  present  time  is  the  Lewisohn  transfusion.  It  has  been 
demonstrated  that  chemically  pure  sodium  citrate  in  solution 
will  prevent  blood  from  clotting,  and  if  used  in  a  strength  not 
exceeding  two-tenths  per  cent,  will  not  prove  injurious  to  the 
patient.     The  usual  procedure  is  as  follows : 

The  donor  is  bled  into  a  flask  containing  enough  sterile 
sodium  citrate  solution  to  prevent  clotting,  and  as  the  blood 
flows  from  the  vein  of  the  donor  into  the  glass  container,  it  is 
slowly  shaken  so  as  to  insure  complete  mixing  with  the  citrate. 
The  drawn  blood,  now  rendered  uncoagulable,  may  be  given  at 
once,  or,  if  it  is  not  practical,  it  may  be  kept  on  ice  and  used 
any  time  wdthin  twenty-four  hours,  provided  it  is  warmed  to 
the  body  temperature  before  injection.  As  a  rule,  the  blood 
is  given  to  the  recipient  by  the  "gravity  method."  This  per- 
mits it  to  flow  by  gravity  from  a  container  elevated  about  two 
or  three  feet  above  the  head  of  the  patient  into  the  vein  of  the 
recipient  through  the  ordinary  Luer  needle  which  has  previ- 
ously been  inserted.  Or,  it  may  be  given  by  the  gravity  method 
plus  a  three-way  stop-cock  and  Luer  syringe.     The  blood  flows 


SHOCK  AND  HEMORRHAGE  17 

from  the  container  into  the  syringe.  When  this  is  filled  the 
cock  is  turned  and  the  syringe  emptied  of  its  contents  by  piston 
pressure,  the  blood  passing  into  the  vein.  Then  the  stop-cock 
is  turned  again  and  the  syringe  refilled.  This  technic  is  elab- 
orate but  there  are  no  real  advantages  over  the  gravity  method, 
(The  apparatus  used  is  the  same  as  for  any  saline  infusion; 
it  should  be  boiled  in  distilled  water.) 

Some  surgeons  prefer  to  give  blood  from  which  the  fibrin 
has  been  removed  by  beating  fresh  blood  with  an  instrument 
similar  to  an  egg-beater.  This  procedure  prevents  it  from  clot- 
ting, and  the  defibrinated  blood,  like  the  citrated,  may  be  kept 
for  some  time  before  its  administration.  The  amount  of  blood 
given  is  usually  500  c.c.  and  this  may  be  repeated  as  often  as 
is  necessary. 

After  Treatment. — After  most  transfusions  there  is  apt  to 
be  a  reaction  manifested  by  chills  and  fever  and  sometimes 
nausea  and  vomiting.  The  nurse  should  always  be  prepared 
for  this  emergency.  This  may  occur  from  ten  to  twenty  min- 
utes after  the  transfusion,  and  the  treatment  is  the  same  as  for 
any  chill, — blankets,  hot  bottles  and  a  little  brandy,  if  per- 
mitted. It  is  advisable  to  save  the  urine  of  all  these  cases  be- 
cause it  should  be  examined  for  the  presence  of  altered  blood. 
This  will  indicate  whether  the  recently  given  blood  has  been 
of  value  to  the  patient,  or  whether  it  has  been  destroyed,  and 
is  being  eliminated  by  the  kidneys. 

Hemorrhage. — Hemorrhage  is  any  bleeding.  It  may  be 
either  arterial,  venous,  or  capillary.  Arterial  hemorrhage  is 
recognized  by  a  stream  of  blood  which  is  bright  red  and  spurt- 
ing, each  spurt  corresponding  to  a  cardiac  systole,  or  contrac- 
tion period  of  the  heart.  Venous  bleeding  is  a  slower,  steadier 
stream  of  dark  red  blood.  Capillary  bleeding  is  evidenced 
by  simple  oozing. 

Symptoms. — If  the  bleeding  is  external,  the  hemorrhage  is 
recognized  rather  readily,  but  if  it  is  internal  bleeding,  it  is 
moderately  difficult  to  diagnose.  Patients  who  are  hemorrhag- 
ing internally  as  the  result  of  some  intra-abdominal  injurj^, 
or  from  the  rupture  of  blood  vessels,  as  in  a  ruptured  ectopic 
pregnancy,  usually  show  pallor,  pinched  face,  cold  clammy  skin, 


18  TEXTBOOK  OF  SURGICAL  NURSING 

rapid  thready  pulse,  shallow  superficial  respirations,  and  what 
is  very  important — "air  hunger,"  Air  hunger  is  one  of  the 
diagnostic  signs  of  hemorrhage.  In  shock  the  patient  is  ordi- 
narih^  quiet,  somewhat  depressed.  In  hemorrhage,  the  patient 
is  gasping  for  breath,  restless,  asking  to  have  the  windows  open, 
begging  for  more  air,  and  feeling  as  if  he  were  being  smothered. 

Treatment. — If  a  large  artery  has  been  cut,  the  first  aid 
treatment  is  simply  to  arrest  the  hemorrhage  b}'  applying  pres- 
sure with  a  tourniquet.  This  is  a  band  placed  around  a  limb, 
and  tightened  until  circulation  through  the  artery  is  arrested. 
It  is  an  excellent  method  for  the  temporary  arrest  of  hemor- 
rhage until  some  medical  aid  can  be  secured  and  the  vessel 
clamped  and  tied. 

Ligature. — This  is  the  tying  off  of  a  vessel  with  material 
which  may  be  either  absorbable,  such  as  catgut,  or  non-absorb- 
able,  such  as  linen.  If  the  vessel  is  moderately  small  and  has 
been  caught  in  an  artery  clamp,  sometimes  by  twisting  the 
arterial  wall,  hemostasis  is  secured.  This  method  is  known  as 
torsio7i. 

Hemorrhage  may  also  be  controlled  by  means  of  the  cautery; 
heat  is  applied  to  the  bleeding  vessel  so  that  it  coagulates  the 
tissues  and  the  bleeding  stops. 

Pressure. — Pressure  is  indeed  a  very  important  means  of 
arresting  hemorrhage,  and  sometimes  good  steady  pressure  over 
a  bleeding  surface  may  do  much  to  stop  the  flow  of  blood.  In 
bleeding  from  bone,  one  of  the  most  efficacious  ways  of  con- 
trolling it  is  to  plug  the  hole  in  the  bone  with  Horsley's  wax. 
This  is  composed  of  seven  parts  beeswax,  one  part  almond  oil, 
and  one  part  salicylic  acid. 

Capillary  Bleeding. — There  are  various  ways  in  which  ooz- 
ing can  be  controlled.  One  is  by  means  of  cold  and  the  other 
by  heat.  Cold  is  especially  efficacious  in  those  operations  about 
the  mouth.  For  example,  after  the  removal  of  adenoids  and 
tonsils,  or  operations  in  the  nose  or  upon  the  palate,  bleeding 
is  often  controlled  by  slapping  the  face  and  neck  with  ice  cold 
water.  It  appears  that  the  contraction  of  the  superficial  ves- 
sels leads  to  a  contraction  of  the  deeper  vessels,  thus  relieving 
the  hemorrhage.     Bleeding  from  the  capillary  blood  bed  of  the 


SHOCK  AND  HEMORRHAGE  19 

uterus  should  not  be  controlled  by  tlic  application  of  cold  water 
as  such  a  procedure  might  result  in  shock.  Instead,  an  intra- 
uterine douche  with  a  little  acetic  acid  and  water  of  from  110 
to  115  degrees  is  excellent  in  controlling  this  variety  of  hemor- 
rhage. Often  it  is  necessary  to  supplement  this  with  packing, 
either  with  jjlain  or  medicated  gauze. 

Styptics. — Occasionally  for  very  small  pin  point  oozing, 
fused  silver  nitrate  is  applied  directly  to  the  bleeding  point. 

After  Treatment  of  Hemorrhage. — Inasmuch  as  a  certain 
amount  of  fluid  is  lost,  it  is  very  important  to  supply  this  to  the 
system  either  by  the  blood  itself  in  the  form  of  transfusions,  or 
by  saline  infusions.  After  the  hemorrhage  has  been  controlled, 
necessity  may  demand  that  the  patient  be  treated  as  a  "  shock ' ' 
case. 


CHAPTER  III 

POST-OPERATIVE  COMPLICATIONS 

The  operation  completed,  the  surgeon  has  done  the  major 
part  of  his  work,  and  the  patient  from  then  on  is  entrusted  to 
the  care  of  the  attending  nurse.  It  is  true  that  all  orders  are 
given  by  the  attending  surgeon,  but  their  conscientious  exe- 
cution is  dependent  upon  the  integrity  and  efficiency  of  the 
nurse.  The  surgeon  may  see  the  case  but  once  a  day ;  the  nurse 
sees  the  patient  at  all  times;  and  she,  by  her  careful  attention 
to  details  and  her  knowledge  of  human  nature,  can  do  much 
to  make  the  patient  comfortable  and  the  post-operative  course 
smooth  in  spite  of  the  many  complications  which  might  arise. 
The  immediate  care  of  the  patient  after  leaving  the  operating 
room  is  discussed  in  Chapters  XIII  and  XVI.  It  is  the  pur- 
pose of  this  chapter  to  discuss  the  treatment  of  the  various  post- 
operative complications.  The  most  important  of  these  are 
nausea,  vomiting,  pernicious  vomiting,  gastric  dilatation,  tym- 
panites, auto-intoxication,  post-operative  pneumonia,  pulmonary 
embolism,  urinary  retention,  urinary  suppression,  phlebitis, 
thrombosis,  and  hemophilia. 

Nausea  is  quite  common.  It  is  usually  present  after  all 
operations  for  a  short  time.  Some  doctors  are  in  the  habit  of 
ordering  cracked  ice  to  relieve  this  distressing  symptom.  AVhen- 
ever  it  is  ordered,  care  must  be  taken  lest  the  patient  get  too 
much  and  in  this  way  imbibe  large  quantities  of  cold  water 
with  the  result  that  vomiting  is  very  apt  to  ensue.  When  the 
feeling  of  nausea  becomes  very  severe  it  is  accompanied  by 
vomiting.  If  a  patient  vomits  later  than  twenty-four  hours 
after  operation,  there  probably  is  something  in  the  stomach 
which  is  causing  a  persistent  irritation.  Once  this  irritation 
is  removed,  the  vomiting  will  generally  cease.  It  must  be  re- 
membered that  the  patient  has  just  been  operated  upon,  and 

20 


POST-OPERATIVE  COMPLICATIONS  21 

that  the  nerves  are  exhausted,  and  that  conservative  treatment 
is  better  than  radical.  The  most  effective  procedure  for  ridding 
the  stomach  of  foreign  material  is  gastric  lavage;  but  washing 
the  stomach  is  trying  and  tiring  and  should  only  be  employed 
when  other  simpler  methods  have  proven  unsuccessful.  First 
the  following  should  be  tried: — A  glassful  or  approximately 
eight  ounces  of  lukewarm  water  with  about  a  teaspoonful  of 
bicarbonate  of  soda  should  be  administered  by  mouth.  As  a 
rule,  patients  are  very  thirsty  after  operation,  and  avariciously 
drink  the  proffered  water.  The  result  is  that  they  are  further 
nauseated  and  soon  vomit  the  ingested  water,  thus  washing  out 
the  stomach,  and  instant  relief  often  ensues.  Sometimes,  in 
spite  of  these  measures,  vomiting  will  still  persist.  It  is  due 
then  to  atony,  a  relaxation  of  the  muscles  of  the  stomach  wall. 
Persistent  vomiting  is  very  weakening,  and  gastric  lavage 
should  be  given  almost  immediately,  if  the  bicarbonate  of  soda 
and  water  fail  to  afford  relief.  A  post-operative  lavage  must  be 
of  hot  water,  for  the  heat  itself  is  the  efficient  agent  in  stimulat- 
ing the  stomach  walls  to  contract,  and  therefore  the  water 
should  be  introduced  at  about  108-110  degrees  Fahrenheit.  An- 
other point, — as  little  air  as  possible  should  enter  the  stomach 
tube,  and  when  the  lavage  is  finished,  the  water  should  be  care- 
fully siphoned  off  from  the  stomach.  If  the  vomiting  persists 
after  a  good  gastric  lavage,  it  then  may  be  due  to  either  per- 
nicious vomiting  or  possibly,  gastric  dilatation. 

Pernicious  Vomiting. — This  may  occur  in  children  as  well  as 
in  adults,  and  is  usually  a  manifestation  of  what  is  commonly 
spoken  of  as  "acidosis,"  a  condition  in  which  the  normal  alka- 
linity of  the  blood  is  diminished.  It  is  recognized  by  the  sweet 
and  fruity  odor  of  the  breath.  If  this  condition  be  suspected, 
the  urine  should  be  examined  for  the  presence  of  acetone.  If 
it  be  present,  gastric  lavage  should  be  given,  everything  stopped 
by  mouth,  and  alkalis  administered  immediately  either  by  a 
ten  per  cent,  sodium  bicarbonate  solution  in  a  Murphy  drip,  or 
intravenously  in  three  to  five  per  cent,  solution,  but  never  by 
clysis. 

Sodium  bicarbonate  is  given  until  it  is  excreted  by  the  kid- 
neys.    When  the  urine  is  alkaline  it  is  safe  to  assume  that  suf- 


22  TEXTBOOK  OF  SURGICAL  NURSING 

fieieut  bicarbonate  has  been  administered  to  bring  the  blood 
back  to  its  normal  alkaline  reaction,  thus  reducing  the  acidosis 
Avhich  is  the  underlying  cause  of  vomiting  in  these  particular 
cases.  There  is  one  point,  however,  -which  needs  emphasis  in 
the  administration  of  sterile  sodium  bicarbonate  solutions. 
After  the  desired  solution  has  been  compounded,  it  must  be 
sterilized.  Sterilization,  by  its  heat,  drives  off  carbon  dioxide 
thereb}'  reducing  the  bicarbonate  of  soda  to  sodium  carbonate. 
This  compound  is  not  as  good  as  the  bicarbonate  because  it  is 
more  irritating  to  the  tissues,  and  is  not  as  effective  in  reestab- 
lishing the  aUialinity  of  the  blood.  To  counteract  this,  after 
the  solution  has  been  cooled  sufficiently,  carbon  dioxide  may 
again  be  added  by  connecting  a  sterile  tube  to  a  carbon  dioxide 
tank  and  allowing  the  gas  to  bubble  through  the  sodium  car- 
bonate fluid  for  a  sufficient  length  of  time,  thus  making  a  bi- 
carbonate compound. 

Gastric  Dilatation. — One  of  the  most  distressing  complica- 
tions which  may  arise  after  an  operation,  and  one  which,  if 
not  treated  radically,  energetically,  and  thoroughly  may  result 
in  death,  is  acute  gastric  dilatation.  As  the  name  implies,  in 
this  condition  the  stomach  becomes  enormously  dilated,  and 
presses  upward  on  the  diaphragm.  This  makes  respiration 
very  difficult  because  of  the  constant  pressure  on  the  diaphragm. 
And,  inasmuch  as  the  pyloric  orifice  of  the  stomach  is  atonic, 
the  intestinal  contents  seep  back  into  the  stomach,  resulting  in 
persistent  vomiting  of  large  amounts  of  greenish  and  brownish 
colored  fluids.  To  relieve  this  condition  those  means  must  be 
employed  which  will  cause  the  dilated  stomach  to  contract  and 
approach  its  normal  size. 

Treatment. — The  stomach  should  be  lavaged  with  a  hot  soda 
bicarbonate  solution  at  110  to  112  degrees  Fahrenheit,  and  the 
lavage  continued  until  the  return  is  absolutely  clear.  While 
this  treatment  is  under  way,  turpentine  stupes  should  be  ap- 
plied to  the  upper  abdomen  for  ten  or  fifteen  minutes.  It  is 
important  to  bear  in  mind  that  as  these  stupes  must  be  hot  to 
be  efficacious,  the  abdomen  should  be  thoroughly  greased  with 
vaseline  before  appljdng  them,  as  great  care  must  be  taken  that 
the  skin  is  not  burned.    The  integrity  of  the  skin  must  be  pre- 


POST-OPERATIVE  COMPLICATIONS  23 

served  because  this  procedure  is  to  be  repeated  every  two  or 
three  hours,  according  to  the  discretion  of  the  attending  surgeon. 
The  stupe  probably  is  the  most  efficient  and  reliable  method 
for  applying  external  heat,  although  some  authorities  advise 
the  use  of  huge  flaxseed  poultices.  Strychnine  sulphate,  gr. 
1/60,  may  be  given  by  hypodermic  injection  every  four  hours, 
following  the  principle  that  the  strychnine  will  improve  muscle 
tone. 

The  patient,  of  course,  during  this  period,  should  be  given 
nothing  by  mouth,  but  measures  should  be  taken  to  supply  the 
system  with  water.  By  persistent  vomiting  these  unfortunate 
patients  have  desiccated  themselves  of  fluid,  and  it  is  necessary 
that  fluid  be  administered  by  means  of  a  Murphy  drip,  or  that 
eight  ounces  of  tap  water  be  given  by  rectum  every  four  hours. 
If  the  patients  show  signs  of  shock,  which  they  often  do,  a 
hypodermoclysis  of  500  to  800  c.c.  of  saline  should  be  given, 
or,  in  some  instances,  an  infusion  of  saline.  If  nourishment 
be  an  essential  element,  a  solution  (two  to  five  per  cent.)  of  glu- 
cose may  be  administered  intravenously.  The  glucose  may  also 
assist  in  combating  a  beginning  acidosis  brought  on  by  inanition. 

After  the  initial  period  of  vomiting  has  come  to  an  end, 
it  is  advisable  to  give  the  stomach  an  absolute  rest  for  about 
twenty-four  hours,  and  then  to  start  the  patient  on  what  may 
be  called  a  "gastric  tolerance  diet."  The  theory  of  this  diet 
is  to  partially  desensitize  the  mucosa  of  the  stomach  and  make 
it  more  tolerant  to  fluids  by  the  use  of  small  doses  of  chloro- 
form water.  If  this  is  retained,  peptonized  milk  is  then  started 
in  small  doses.  The  amount  of  peptonized  milk  is  then  gradually 
increased,  the  chloroform  water  is  omitted,  and  the  patient, 
after  a  period  of  absolute  gastric  tolerance,  is  gradually  brought 
over  to  a  selected  soft  diet.  The  exact  details  of  this  diet 
are  given  in  Chapter  XII  on  ''Surgical  Dietetics." 

Tympanites. — The  distention  of  an  abdomen  following  op- 
eration is  due  to  a  gastric  dilatation,  a  distention  of  the  small 
or  large  intestine,  or  a  dilatation  of  the  bladder  resulting  from 
urinary  retention.  The  word  tympanites  or  meteorism  de- 
notes an  inflation  of  the  abdomen  with  gas.  This  gas  is  usually 
intestinal;  occasionally  it  may  be  free  in  the  peritoneal  cavity 


24  TEXTBOOK  OF  SURGICAL  NURSING 

from  a  perforation  of  the  intestines.  A  condition  of  gastric 
dilatation  is  recognized  by  distention  in  the  upper  abdomen; 
that  of  the  small  or  large  intestine,  by  a  generalized  abdominal 
distention;  that  of  the  bladder  by  palpation  of  a  rounded  mass 
just  above  the  pubes  and  the  failure  of  the  patient  to  void  after 
operation.  Tympanites  is  certainly  distressing  and  modern 
surgical  nursing  commands  many  methods  to  alleviate  and  re- 
lieve this  condition,  bringing  much  comfort  to  the  patient. 

Treatment. — The  theory  underljdng  all  treatments  is  to  aid 
the  patient  in  ridding  the  small  intestines  and  colon  of  gas. 
The  means  for  accomplishing  this  are  many.  One  of  the  simplest 
procedures  and  one  of  the  most  efficient  is  the  introduction  of 
a  rectal  tube. 

A  rectal  tube  is  a  small  piece  of  rubber  tubing  about  three- 
eighths  of  an  inch  in  diameter,  rounded  at  one  extremity.  This 
is  well  lubricated  with  either  K-Y  or  vaseline,  and  gently  in- 
troduced into  the  rectum  beyond  the  internal  and  external 
sphincters,  and  about  three  to  four  inches  beyond  the  anus. 
The  purpose  is  to  form  an  exit  for  gas  which  may  have  accumu- 
lated in  the  colon.  This  simple  procedure  is  often  all  that  is 
necessary. 

Enemas. —  Especially  in  emergencies  when  the  patient  has  not 
had  a  cathartic,  or  a  thorough  intestinal  cleansing  before  the 
operation,  the  fecal  material  is  apt  to  accumulate  in  the  colon 
causing  fermentation  and  often  stopping  the  passage  of  gas  or 
flatus  by  its  mechanical  bulk.  In  these  conditions  it  is  im- 
portant to  empty  the  lower  bowel  by  a  cathartic  enema.  The 
soapsuds  enema  is  usually  all  that  is  required.  But  in  those 
cases  where  the  soapsuds  have  brought  very  little  return,  and 
the  distention  is  still  marked,  and  it  is  thought  that  fecal  ma- 
terial is  being  retained,  it  is  advisable  to  give  a  more  purga- 
tive enema.  The  solutions  which  may  be  added  to  enemas  may 
be  glycerine,  one  ounce,  or  turpentine,  %  ounce  to  the  pint. 
Milk  and  molasses, — four  ounces  of  milk  and  four  ounces  of 
molasses, — make  a  good  irritative  enema.  The  magnesium  sul- 
phate enema  is  used  now  quite  frequently, — two  ounces  each 
of  water,  glycerine  and  magnesium  sulphate  in  saturated  solu- 
tion being  employed.     Some  institutions  use  a  mixture  with 


POST-OPERATIVE  COMPLICATIONS  25 

oxgall  in  the  following  proi)oi'tions : — turpentine  o  ii,  oxgall  o  ii, 
magnesium  sulphate  §  iv,  glycerine  §  iv. 

These  purgative,  irritative  enemas,  not  only  empty  the  lower 
bowels,  but  also  stimulate  the  smooth  muscles  to  contract, 
thus  expelling  the  gas  which  has  accumulated.  Irritative  enemas 
for  safety's  sake  should  be  small  in  amount.  The  soapsuds 
enema,  however,  made  from  castile  or  ivory  soap,  is  given  in 
amounts  varying  from  two  to  four  pints.  After  operation,  it 
is  best  to  give  the  enema  in  the  dorsal  position,  putting  the 
douche  pan  under  the  patient  before  the  enema  is  given.  The 
returns  should  be  watched  for  the  presence  of  fecal  material, 
mucus,  blood,  bile,  and'  gas.  Enemas  after  operation  should 
always  be  ordered  by  the  attending  physician,  and  no  nurse 
should  take  upon  herself  the  responsibility  of  injecting  fluid 
into  the  rectum.  As  a  rule,  they  should  not  be  given  in  rectal 
cases,  perineorrhaphies,  or  resections  of  the  colon  unless  abso- 
lutely essential. 

Colon  Irrigation. — The  colon  irrigation  performs  three 
functions:  It  supplies  a  certain  amount  of  fluid  to  a  system 
which  needs  water;  it  carries  off  fecal  material,  and  acts  as  a 
medium  for  the  expulsion  of  gas.  Colon  irrigations  when  given 
properly  should  cause  the  patient  absolutely  no  distress.  If 
perfectly  given,  there  is  no  reason  why  the  patient  should  not 
fall  asleep  during  the  treatment.  Many  solutions  are  used 
for  the  irrigations.  Normal  or  half  strength  saline  is  quite 
common,  but  it  must  be  remembered  that  it  increases  the  thirst 
of  the  patient,  and  for  this  reason,  provided  that  the  rectum 
will  retain  it,  tap  water  is  better.  Any  irrigation  to  be  effec- 
tive must  be  given  hot,  at  a  temperature  varying  from  110-120 
degrees.  About  three  gallons  should  be  used  for  a  single  ir- 
rigation. "While  the  technic  of  giving  an  irrigation  is  known 
to  every  nurse,  there  are  a  few  points  which  might  be  em- 
phasized, and  which  if  remembered,  will  cause  greater  com- 
fort to  the  patient.     They  are  as  follows : 

1.  All  air  must  be  expelled  from  the  inflow  catheter  before 
it  is  inserted. 

2.  The  catheter  should  be  inserted  within  the  outflow  tube 
so  that  only  one  tube  is  inserted  into  the  rectum. 


26  TEXTBOOK  OF  SURGICAL  NURSING 

3.  The  end  of  the  outflow  tube  should  not  be  more  than  a 
foot  below  the  level  of  the  patient.  If  it  is,  a  jerky  interrupted 
flow  is  apt  to  result  because  too  great  a  suction  is  established, 
and  the  mucous  membrane  of  the  rectum  is  apt  to  be  drawn 
about  the  holes  of  the  rubber  tubing. 

4.  There  should  always  be  a  return  of  fluid  through  the  out- 
flow and  if  for  any  reason  it  is  not  evident,  the  irrigation  should 
be  stopped  immediately.  For  the  pressure  of  fluid  through 
the  inflow  tube  might  be  so  strong  as  to  cause  distention  with 
a  resulting  paresis  of  the  gut ;  or,  what  is  extremely  rare,  there 
might  be  a  perforation  in  the  colon  through  which  fluid  empties 
itself  into  the  peritoneal  cavity.  The  amount  of  fluid  which 
the  patient  absorbs  can  easily  be  estimated  by  comparing  the 
amount  given  and  the  amount  returned. 

There  are  two  ways  of  giving  a  colon  irrigation: — one  way 
is  to  use  an  inflow  and  outflow  tube ;  the  other,  one  tube  to  serve 
alternately  as  inflow  and  outflow.  The  second  method  is  less 
advisable,  for  it  is  more  like  an  intermittent  enema,  and  is 
certainly  more  uncomfortable  to  the  patient. 

Aids  to  Colon  Irrigations. — Just  as  in  a  dilatation  of  the 
stomach  water  is  applied  internally  and  heat  externally  by  the 
application  of  poultices,  so,  in  giving  a  colon  irrigation,  to 
make  it  more  effective,  and  to  aid  in  stimulating  the  contrac- 
tion of  the  smooth  muscle  of  the  bowel,  large  flaxseed  poultices 
are  used  for  their  counter-irritative  effects.  In  addition,  very 
often  1  c.c.  of  pituitrin  is  given  intramuscularly  during  the 
colon  irrigation.  It  is  a  known  fact  that  a  substance  in  the 
posterior  lobe  of  the  pituitary  stimulates  smooth  muscles  to 
contract.  Pituitary  extract  should  not  be  given  by  mouth  be- 
cause its  administration  in  that  manner  is  practically  ineffectual. 
In  some  cases,  fortunately  rare,  rectal  tubes,  enemas  and  colon 
irrigations  will  not  relieve  abdominal  distention.  These  cases 
are  spoken  of  as  paralytic  ileus. 

This  is  a  condition  in  which  the  smooth  muscle  of  the  in- 
testine is  practically  paralyzed;  there  is  no  peristalsis,  no  pas- 
sage of  gas,  the  patient  becomes  more  and  more  distended  as 
the  fermentation  becomes  greater  and  the  toxemia  becomes 
more  severe.     This  condition  is  helped  by  immediate  surgical 


POST-OPERATIVE  COMPLICATIONS  27 

interference  alone.  The  mortality,  however,  is  terrifically  high. 
The  operation  performed  is  an  enterostomy,  Chapter  IV,  page 
55;  an  opening  is  made  in  the  small  intestine  through  which  the 
gas,  fluid  and  solid  material  may  escape.  Thus  with  a  diminu- 
tion of  the  degree  of  toxemia,  and  the  intestines  relieved  of 
their  burden  they  will  have  sufficient  strength  and  recuperative 
powers  to  regain  their  normal  tone  and  peristaltic  wave  action. 

Auto-intoxication. — Closely  allied  to  meteorism  is  auto-in- 
toxication. In  this  condition  the  patient  absorbs  certain 
products  of  fermentation  and  decomposition  from  the  gastro- 
intestinal tract,  resulting  in  a  slight  degree  of  temperature 
usually  associated  with  headache  and  general  malaise.  This  is 
ordinarily  relieved  by  a  movement  of  the  bowels,  procured  by 
an  enema,  and  a  cathartic.  This  condition  is  never  very  seri- 
ous, and  never  alarming. 

Post-operative  Pneumonia. — This  is  one  of  the  most  serious 
of  post-operative  complications.  Often  a  patient  reacts  favor- 
ably to  an  operation  only  to  be  dragged  down  in  a  day  or 
two  by  the  toxemia  of  lung  involvement ;  and  this,  together 
with  the  general  weakness  following  surgical  interference, 
often  results  in  death.  While  pneumonia  cannot  be  absolutely 
obviated  as  a  post-operative  complication,  there  can  be  a 
marked  diminution  in  its  frequency  if  greater  attention  is  paid 
to  the  smaller  details  of  ante-operative  and  post-operative  care. 

In  hospital  work  and  in  private  nursing  the  fact  is  often 
forgotten  that  the  patient  in  his  home  has  been  accustomed  to 
certain  clothing  and  has  been  living  for  years  under  peculiar 
hygienic  conditions.  Upon  entering  the  hospital  he  is  given 
an  abbreviated  nightgown  and  placed  in  a  bed  with  one  or  two 
blankets.  When  he  is  physically  examined  his  gown  is  taken 
off,  and  very  often  there  is  a  draught  from  a  nearby  open  win- 
dow. The  deep  breathing  and  coughing  incident  to  the  auscul- 
tation of  the  lungs  often  cause  a  perspiration,  and  the  cool  air 
on  the  heated  skin  is  a  poor  combination.  Occasionally  the  pa- 
tient is.  asked  to  get  out  of  bed  and  stand  up,  his  bare  feet 
very  often  resting  against  the  cold  floor;  or  often,  when  the 
abdomen  is  shaved  and  being  prepared  for  operation,  the  pa- 
tient is  unduly  exposed.     Then  from  a  warm  bed  he  is  placed 


28  TEXTBOOK  OF  SURGICAL  NURSING 

upon  a  cold  stretcher,  wheeled  through  draughty,  chilly  halls, 
and  plunged  into  a  superheated  operating  room.  During  the 
operation  he  is  apt  to  perspire  freely,  and  while  it  is  routine 
to  change  a  drenched  gown,  the  patient,  through  neglect,  is 
often  permitted  to  keep  it,  and  in  this  condition  he  is  sent 
through  the  halls  again,  back  into  the  ward.  During  the  re- 
covery period,  he  may  toss  around,  uncovering  his  body,  and  ex- 
posing his  depressed  system  to  more  draughts,  more  chilling, 
opening  the  way  to  a  pneumonia.  When  the  matter  is  given 
thought,  the  real  wonder  is  that  pneumonia  is  not  more  fre- 
quent. The  best  method  of  treating  this  serious  complication 
is  by  prophylaxis.  Prevention  is  better  than  cure,  and  careful 
and  conscientious  surgical  nursing  will  greatly  aid  in  diminish- 
ing the  incidence  of  this  dreaded  complication. 

Prophylactic  Treatment. — Ante-operative. — All  patients  be- 
fore operation  should  be  carefully  examined  for  coryza,  bron- 
chitis, pharyngitis,  or  tonsillitis,  and  if  any  of  these  exist,  the 
operation  should  not  be  performed,  but  temporarily  postponed. 
Of  course,  acute  cases  fall  into  another  category,  and  very 
often  it  is  advisable  to  do  these  under  local  anesthesia  rather 
than  run  the  risk  of  ether  or  gas  administration  which  is  sure 
to  spread  the  infection  into  the  lungs.  If  the  nurse  at  any 
time  prior  to  operation  notices  that  the  patient  sneezes  exces- 
sively, or  that  signs  of  a  cold  are  developing,  it  is  imperative 
that  she  immediately  notify  the  surgeon,  for  few  will  operate 
when  there  is  even  the  slightest  infection  of  the  respiratory 
system. 

When  patients  are  being  examined  physically,  or  receiving 
treatments,  it  is  highly  important  that  all  windows  and  doors 
in  the  vicinity  be  closed  and  that  draughts  be  diminished  to  the 
minimum.  If  a  patient  has  to  leave  the  bed  he  should  be  ade- 
quately supplied  with  slippers,  a  bathrobe,  and,  if  necessary, 
a  blanket.  When  he  is  moved  to  and  from  the  operating  room 
he  should  be  warmly  covered,  and  in  the  operating  room  the 
same  general  rules  hold  true.  If  his  gown  becomes  wet  with 
perspiration,  his  body  should  be  thoroughly  dried  and  a  new 
gown  supplied. 

Operative  Prophylactic  Treatment. — While   the   patient   is 


POST-OPERATIVE  COMPLICATIONS  29 

recovering  from  the  anesthetic,  the  lower  jaw  .should  be  hehl 
firmly  and  pressed  forward,  exerting  pressure  at  both  angles; 
this  will  do  much  to  prevent  gagging  and  when  the  patient  vomits 
the  head  should  be  turned  to  one  side,  the  jaw  still  being  held, 
and  the  vomitus  eructated  into  a  pus  basin.  It  is  highly  im- 
portant that  this  be  always  done,  because  if  this  procedure  is 
routinely  and  regularly  followed,  the  danger  of  the  vomitus 
being  aspirated  into  the  lungs  is  reduced.  Aspiration  is  not  an 
uncommon  cause  of  pneumonia. 

Post-operative  Prophylactic  Treatment. — When  the  patient 
arrives  in  the  ward  or  room  he  should  be  warmly  covered,  and 
very  often  in  order  to  maintain  a  good  body  heat,  the  bed  may 
be  previously  warmed  either  with  electric  pad  or  hot  water 
bottles.  If  the  patient  tosses  about,  the  blankets  should  always 
be  readjusted.  If  there  is  a  tendency  to  vomit  the  jaw  should 
be  held  firmly  forward  and  the  head  turned  to  one  side.  These 
instructions  have  been  repeated  because  it  is  extremely  im- 
portant that  they  become  deeply  impressed  upon  the  nursing 
mind.  In  other  words,  the  incidence  of  post-operative  pneu- 
monia may  be  greatly  reduced  if  the  patient  before  operation 
is  free  of  any  infection  of  the  respiratory  tract,  and  during  the 
period  of  surgical  attention  he  be  fully  protected  against 
draughts  and  unusual  changes  from  cold  to  hot  or  hot  to  cold. 

Treatment  of  Post-operative  Pneumonia. — The  treatment  is 
really  that  of  any  lobar  pneumonia.  The  patient  is  usually 
on  a  Gatch  bed.  The  Gatch  bed  is  one  which  is  made  in  sections 
so  that  the  upper  portion  of  the  body  may  be  elevated  and 
the  knees  flexed  by  adjusting  these  sections  to  any  desired  de- 
gree. 

The  windows  are  opened  wide  and  as  much  fresh  air  is 
given  as  is  possible.  The  diet  is  liquid  including  milk.  Fluids 
should  be  forced  to  about  3,000  c.c.  a  day,  and  the  intake  and 
output  should  be  accurately  measured. 

Abdominal  distention  is  always  looked  for  and  treated  im- 
mediately -with  rectal  tube,  enemas  or  colon  irrigations. 

The  cough  is  particularly  distressing  and  dangerous,  for 
after  a  surgical  operation  the  pressure  caused  by  straining  may 
break  some  of  the  sutures  and  sometimes  the  abdominal  wound 


30  TEXTBOOK  OF  SURGICAL  NURSING 

is  ruptured  Avido  opeii,  and  the  abdominal  contents  eviscerated. 
To  prevent  this  horribk?  complication  a  good,  tight,  well-placed 
binder  is  exceedingly  important,  for  it  gives  added  support  to 
the  abdominal  wall.  If  the  coughing  is  very  severe,  the  nurse 
should  supi)ort  the  lateral  areas  of  the  abdominal  wall  with 
her  hands.  Should  evisceration  take  place,  the  intestines  should 
be  covered  with  sterile  towels,  and  the  surgeon  immediately 
summoned.  For  the  cough,  doctors  will  prescribe  a  codeine 
cough  mixture,  or  leave  orders  for  codeine  to  be  given  either 
by  mouth  or  hypodermic. 

As  soon  as  the  diagnosis  is  made,  it  is  routine  to  administer 
tincture  of  digitalis  as  a  cardiac  stimulant,  the  dose  being  10 
to  15  minims  three  times  a  day.  If  the  pulse  is  very  rapid, 
and  the  heart  overacting,  it  is  controlled  by  an  ice  bag  placed 
over  the  precordium. 

Pleural  pain,  which  is  very  distressing,  yields  to  strapping 
the  affected  side  with  adhesive  plaster. 

Pneumonia  cases  must  always  be  watched  carefully  for 
cardiac  failure  and  edema  of  the  lungs.  The  cardiac  failure  is 
evidenced  by  a  weak,  thready  pulse,  cyanosis  and  respiratory 
difficulty.  Edema  of  the  lungs  manifests  itself  by  bubbling 
respirations. 

Cardiac  failure  is  treated  by  stimulants,  such  as  camphor 
in  oil,  caffeine  or  atropine.  Edema  of  the  lungs  responds  best 
to  good  dry  cupping  especially  applied  to  the  posterior  regions 
of  the  chest.  This  should  be  done  for  about  twenty  minutes  at 
a  time.  Great  care  should  always  be  exercised  in  preventing 
the  patient  from  being  burned  with  the  cups.  The  use  of 
oxygen  in  these  cases  with  the  present  apparatus  is  practically 
useless  and  worthless. 

Pulmonary  Embolism. — Closely  allied  to  post-operative 
pneumonia,  but  of  different  etiology,  is  pulmonary  embolism. 
It  is  not  very  common,  and  may  occur  after  the  simplest  opera- 
tions ;  for  example,  after  an  appendicectomy,  or  an  operation  for 
varicose  veins ;  it  may  be  preceded  by  a  thrombosis  of  the  veins 
of  the  lower  extremity,  or  come  as  a  distinct  entity.  As  a  rule, 
it  is  ushered  in  by  a  sudden  pain  in  the  chest,  dyspnea,  bloody 
expectoration,  rapid  pulse,  and  slight  rise  in  temperature.     If 


POST-OPERATIVE  COMPLICATIONS  31 

the  chest  is  auscultated  the  doctor  may  sometimes  note  a  fric- 
tion sound,  or  signs  of  beginning  pneumonia  may  be  evident. 
Occasionally,  instant  death  occurs,  and  at  best  the  mortality 
is  high,  varying  from  seventy  to  eighty  per  cent. 

Treatment. — Patients  who  develop  a  phlebitis  or  thrombosis 
of  the  veins  of  the  lower  extremity,  or  any  other  region, 
should  be  kept  in  bed  until  this  condition  absolutely  sub- 
sides, because  a  small  piece  of  blood  clot  may  break  off  and 
lodge  in  the  lung  as  an  embolus.  Patients  should  not  be  per- 
mitted to  be  too  active  after  operation  even  if  their  condition 
is  excellent.  The  treatment  of  embolism  is  to  reassure  the 
patients,  for  they  are  apt  to  become  greatly  alarmed  at  the 
sight  of  their  bloody  expectoration.  To  further  quiet  them 
morphine  is  administered.  If  the  diagnosis  of  its  location  is 
made,  it  is  customary  to  strap  that  side  of  the  chest  in  which 
the  embolus  is  lodged.  This  will  immobilize  the  affected  lung 
as  much  as  possible. 

The  family  of  a  patient  suffering  from  a  pulmonary  embolism 
should  be  apprised  of  the  impending  danger,  for  even  though 
the  patient  may  recover  from  the  shock  of  the  embolism  itself, 
it  may  give  rise  to  an  embolic  pneumonia  and  a  recovery  from 
this  condition  is  exceptionally  rare  although  it  occasionally 
occurs. 

Urinary  Retention. — After  operation,  occasionally,  a  patient 
is  unable  to  void  urine  voluntarily  with  the  result  that  the 
urine  collects  in  the  bladder,  the  organ  becoming  dilated  be- 
yond its  usual  capacity.  Pain  is  very  apt  to  result  from  this 
distention,  and  the  patient  is  very  uncomfortable.  Urinary 
retention  is  more  prone  to  occur  after  operations  about  the 
rectum,  the  vagina,  the  cervix,  and  the  bladder  itself  than  after 
operations  involving  the  upper  abdomen.  The  reason  for  this 
is  that  the  center  of  micturition  has  been  reflexly  inhibited 
by  the  operative  procedures;  or  it  may  be  due  to  nervousness, 
or  that  conscious  control  has  not  as  yet  been  reestablished  after 
the  administration  of  an  anesthetic.  As  a  rule,  no  patient 
should  be  allowed  to  go  more  than  twelve  to  twenty  hours  with- 
out voiding.     However,  every  effort  should  be  made  to  have 


32  TEXTBOOK  OF  SURGICAL  NURSING 

the  patient  void  voluntarily,  because  all  functions  are  better 
performed  by  nature  than  if  mechanically  interfered  with. 

Treatment. — The  treatment  of  urinary  retention  is  cathe- 
terization. A  catheterization  is  a  surgical  procedure.  A  surgi- 
cal procedure  in  clean  cases  is  an  aseptic  one,  and  every  bladder 
Mliicli  becomes  infected  after  the  introduction  of  the  catheter 
is  a  horrible  reflection  upon  the  individual  Avho  has  done  the 
catheterization.  This  procedure  should  be  done  with  a  good 
light.  The  urethral  orifice  is  carefully  exposed.  The  catheter, 
be  it  rubber,  metal,  or  glass,  should  be  lubricated  with  a  sterile 
oil,  either  olive  oil  or  K.  Y.  The  urine  which  is  withdrawn 
should  be  saved  and  examined  as  a  matter  of  record.  While 
catheterization  every  eight  hours  is  a  routine  in  some  hospitals 
after  perineorrhaphy,  it  should  be  remembered  that  a  patient 
may  develop  a  * '  catheter  habit ' '  because  the  act  of  micturition  or 
urination  causes  slight  pain,  and  catheterization  affords  instant 
relief  without  pain.  These  cases  should  be  treated  firmly  but 
gently  and  various  expedients  should  be  tried  to  induce  volun- 
tary micturition.  The  drinking  of  large  quantities  of  water, 
the  sound  of  running  water  from  turning  on  a  water  faucet 
within  hearing  distance  of  the  patient,  or  pouring  warm  water 
over  the  vulva  may  do  much  to  encourage  voluntary  micturition. 

In  those  cases  where  there  is  an  old  inflammation  of  the 
bladder,  it  is  advisable  not  to  draw  off  all  the  urine  at  once, 
but  to  leave  about  four  ounces  in  the  bladder,  or  if  all  the 
urine  is  withdrawn,  to  introduce  immediately  into  the  bladder 
about  four  ounces  of  a  warm  sterile  solution  of  boric  acid.  This 
will  prevent  any  possibility  of  an  infection  travelling  from 
the  bladder  to  the  kidneys  via  the  ureter.  The  details  of 
catheterization  are  not  given  here,  as  they  are  known  to  every 
nurse,  but  it  cannot  be  emphasized  too  strongly  that  this  treat- 
ment above  all  must  be  done  by  a  nurse  with  a  surgical  con- 
science. 

Suppression  of  Urine. — Following  some  of  the  more  exten- 
sive major  operations,  especially  those  upon  the  kidney,  either 
a  nephrectomy  or  a  nephrotomj^,  or  prostatectomy,  the  kidneys 
may  shut  down  and  secrete  no  urine ;  the  result  is,  that  those 
substances  which  should  be  normally  excreted  in  the  urine  as 


POST-OPERATIVE  COMPLICATIONS  33 

the  urea,  are  stored  up  in  the  blood.  There  is,  however,  a  limit 
to  the  amount  of  nitrogenous  poison  which  the  blood  can  con- 
tain, and  if  this  threshold  is  crossed,  the  patient  may  suffer 
from  uremic  poisoning.  Uremia  is  recognized  by  the  urinous 
odor  of  the  breath,  the  dried  parched  tongue,  a  semicomatose 
attitude  of  the  patient,  the  urinary  suppression,  and  an  in- 
crease in  the  nonprotein  nitrogen  of  the  blood. 

Treatment. — The  prognosis  in  all  these  cases  is  poor.  The 
same  methods  used  by  medical  men  in  combating  uremia  re- 
sulting from  diseased  kidneys  are  used  by  the  surgeon.  If  the 
kidneys  are  incapable  of  physiologically  performing  their  func- 
tion of  elimination,  then  for  the  time  being  other  organs  must 
take  over  that  function.  There  are  many  adjuvants, — ^the  sweat 
glands  of  the  skin  and  the  intestinal  canal  are  invaluable  aids. 
The  reflex  stimulation  of  the  kidneys  by  counter-irritants,  the 
forcing  of  fluids  so  as  to  dilute  the  poison  in  the  blood,  the 
actual  removal  of  some  blood  with  its  poisons  (phlebotomy), 
and,  finally,  operation  upon  the  kidney  itself,  all  help  in  this 
very  serious  complication. 

The  skin  may  be  used  to  further  aid  excretion.  If  the  pa- 
tient will  stand  it,  hot  packs  should  be  employed.  The  pur- 
pose of  a  hot  pack  is  to  cause  perspiration,  and  inasmuch  as 
urea  is  one  of  the  chief  elements  of  sweat,  a  partial  strain  is 
taken  away  from  the  kidneys.  Very  often  this  procedure  alone 
will  be  sufficient  to  stimulate  the  kidneys  to  excrete  urine.  Hot 
packs  should  be  repeated  at  intervals  of  four  to  six  hours. 
While  the  treatment  is  being  administered,  the  condition  of  the 
patient  must  be  carefully  watched,  for  the  packing  often  re- 
sults in  weakness  and  prostration.  The  other  danger  of  giving 
a  pack  to  a  surgical  patient  is  that  the  body  must  be  care- 
fully dried  after  the  treatment  in  order  to  prevent  post-opera- 
tive pneumonia.  In  addition,  great  care  should  always  be 
taken  that  the  skin  (which  has  already  been  made  sensitive 
through  the  application  of  the  ante-operative  painting  of  iodine) 
should  not  be  burned,  and  further  avenues  of  infection  opened 
through  denuded  skin. 

The  use  of  the  intestinal  tract  as  an  avenue  of  elimination 
may  be  further  stimulated  by  employment  of  colon  irrigations. 


34  TEXTBOOK  OF  SURGICAL  NURSING 

The  colon  irrigations,  as  stated  previously,  not  only  carry  off 
large  amounts  of  toxins,  but  tliey  are  a  means  of  supplying 
water  to  the  tissues. 

The  kidneys  may  be  stimulated  reflexly  by  counter-irritants 
applied  to  the  skin  of  the  lumbar  region.  This  may  be  accom- 
plished by  the  use  of  flaxseed  poultices  applied  at  two-hour 
intervals,  or  by  hot  water  bottles.  Some  surgeons  employ  drugs 
in  order  to  stimulate  the  kidneys  directly,  by  the  use  of  such 
substances  as  theobromine  because  of  its  direct  diuretic  action. 
Five  to  eight  grains  are  given  three  times  a  day  for  the  space 
of  three  days  and  then  the  drug  is  stopped.  There  is  no  doubt 
that  this  drug  is  excellent  in  stimulating  the  kidneys  and  cer- 
tainly surpasses  caffeine  in  its  action.  The  disadvantage  is  that 
it  might  cause  a  certain  amount  of  nervousness  and  insomnia. 

Forcing  fluids  either  by  proctoclysis  or  hypodermoclysis  -will 
cause  enough  fluid  to  be  absorbed  to  dilute  the  blood,  thus 
resulting  in  a  diminution  in  the  degree  of  toxemia.  This  simple 
method  not  only  relieves  the  patient  of  an  impending  uremia, 
but  the  kidneys  are  stimulated  by  the  added  amount  of  fluid. 

In  cases  of  high  blood  pressure  with  a  high  blood  urea,  the 
actual  removal  of  part  of  the  blood  volume  will  do  much  to  re- 
duce the  nitrogen  content  of  the  blood,  if  only  for  a  short  period 
of  time.  This  is  done  by  a  phlehotoj^iy,  or  inserting  a  canula  in 
a  vein  in  the  arm,  and  permitting  the  patient  to  be  bled  of 
250  to  700  c.c.  of  blood.  The  amount  withdrawn  should  de- 
pend upon  the  constitution  and  physique  of  the  patient.  Quite 
often  after  this  procedure,  250  to  500  c.c.  of  normal  saline  are 
introduced  intravenously,  resulting  in  further  dilution  of  the 
toxins. 

If,  in  spite  of  all  these  procedures,  there  is  no  urine  ex- 
creted, a  rather  heroic  operative  procedure  may  be  resorted  to, 
that  of  decapsulating  the  kidneys.  This  is  especially  indicated 
in  those  cases  which  have  a  chronic  inflammation  of  the  kidneys, 
preexisting  Bright 's  disease.  The  operation  is  spoken  of  as 
Edebohls's  decapsulation.  It  consists  of  the  excision  of  the 
capsule  from  the  kidney  so  that  with  this  restraint  removed, 
the  organ  may  be  able  to  work  more  efficiently  by  establishing 


POST-OPERATIVE  COMPLICATIONS  35 

new  vascular  relationships  with  the  surrounding  tissues,  thereby 
obtaining  better  nourishment  for  itself. 

Phlebitis. — This  condition  is  an  inflammation  of  the  veins, 
usually  of  the  lower  extremity.  It  is  rather  late  in  onset  and 
is  annoying  because  the  patient  is  confined  to  bed  for  a  longer 
period  of  time.  It  is  manifested  by  cramp-like  pains  in  the  leg, 
a  rise  in  temperature,  and  a  feeling  of  general  malaise.  Ex- 
amination of  the  affected  extremity  shows  that  the  part  is 
swollen  and  the  skin  over  the  veins  reddened.  Occasionally 
the  veins  may  be  palpated.  The  treatment  calls  for  absolute 
rest,  elevation  of  the  affected  part  and  immobilization,  the  part 
being  kept  warm  by  a  wrapping  of  cotton,  or  the  additional 
heat  of  an  electric  pad.  Phlebitis  may  be  associated  with  or 
followed  by  thrombosis. 

Thrombosis. — This  may  follow  in  the  path  of  a  phlebitis,, 
and  simply  means  the  occlusion  of  the  lumen  of  the  vein  with 
a  blood  clot.  The  same  condition  may  occur  in  arteries.  The 
symptoms  are  practically  those  of  a  phlebitis.  The  danger  of 
these  cases  lies  not  so  much  in  thrombosis  itself,  but  the  fact 
that  these  thrombi  may  give  rise  to  small  particles  of  blood 
clots  (emboli)  which  invade  the  blood  stream  and  localize  in 
any  part  of  the  body.  The  symptoms  and  physical  signs  depend 
on  the  area  in  which  these  emboli  have  lodged.  If  it  should 
localize  in  the  brain,  paralysis  might  ensue;  if  in  the  central 
artery  of  the  retina,  blindness ;  if  within  the  coronary  artery 
of  the  heart,  immediate  death.  A  glance  at  these  possibilities 
is  certainly  proof  that  a  thrombosis  is  potentially  a  dangerous 
operative    complication. 

Treatment. — The  acute  condition  is  treated  practically  the 
same  as  a  phlebitis,  with  the  exception  that  the  local  applica- 
tions vary,  some  using  ice  compresses  over  the  veins,  others 
a  20  per  cent,  ichthyol  ointment,  some  the  electric  pad.  All  sur- 
geons believe  in  absolute  rest  of  the  part  involved.  It  is  a 
good  practice  to  keep  the  weight  of  the  bed  clothing  away 
from  the  affected  area,  by  means  of  a  wooden  or  metal  cradle. 
When  all  the  acute  inflammation  has  subsided,  the  patient 
should  not  be  allowed  up  and  out  of  bed  until  a  good  firm  pres- 
sure bandage  has  been  applied.     In  a  leg  case,  the  bandage 


36  TEXTBOOK  OF  SURGICAL  NURSING 

is  -wouud  from  the  ankle  upward  to  the  knee.  The  patient 
should  be  warned  that  even  after  leaving  the  hospital,  or  home, 
that  a  rubber  .storking  jiroperly  fitted  should  be  Avorn  for  a 
long  period  of  time. 

Of  course  when  this  condition  involves  the  superficial  veins 
it  is  not  so  very  serious,  but  it  has  been  known  to  choke  off 
the  femoral  artery,  the  main  channel  through  which  the  lower 
extremity  gets  its  supply  of  blood.  This  might  result  in 
gangrene  with  subsequent  amputation  of  the  leg  and  thigh. 
These  severe  post-operative  complications  are  fortunately  rather 
rare. 

Hemophilia. — As  science  progresses  new  discoveries  are 
made  and  some  certain  operative  complications  may  be  pre- 
vented b}'  prophylactic  measures.  A  disease  no  longer  dreaded 
is  hemophilia  (a  condition  marked  by  a  tendency  to  persistent 
bleeding).  It  would  never  occur  if  routine  coagulation  times 
were  done  on  all  patients  before  they  entered  the  operating 
room.  Blood  usually  clots  in  seven  minutes  and  if  the  period 
of  clotting  is  beyond  eight  minutes,  measures  should  be  insti- 
tuted to  insure  the  clotting  of  the  blood  in  a  shorter  j)eriod. 
There  are  many  conditions  which  interfere  with  the  normal 
clotting  of  blood,  but  one  of  the  most  interesting  of  these  is 
hemophilia.  It  is  a  malady  which  is  transmitted  by  the  female 
to  the  male,  although  rare  instances  have  been  reported  where 
women,  too,  are  the  sufferers.  In  this  disease,  blood  does  not 
clot  often  until  15-20  minutes.  Jaundice  is  another  condition 
which  hinders  the  clotting  of  the  blood.  In  hemophilia  and 
jaundice  and  in  all  cases  in  which  the  clotting  time  is  delayed 
methods  must  be  taken  to  lower  the  coagulation  time  to  within 
normal  limits. 

Treatment. — Before  operation  those  patients  with  a  pro- 
longed coagulation  time  should  be  given  calcium  lactate,  gr.  15, 
three  times  a  day,  in  milk.  If  at  the  end  of  three  days,  the 
coagulation  time  has  not  been  materially  reduced,  they  should 
be  given  about  from  15  to  30  c.c.  of  horse  serum  intravenously. 
This  is  very  valuable  in  lowering  the  coagulation  time.  Be- 
fore the  administration  of  horse  serum,  the  patient  should  be 
carefully  tested  by  the  injection  of  minute  doses  of  horse  serum 


POST-OPERATIVE  COMPLICATIONS  37 

into  the  skin  to  determine  whether  the  individual  is  sensitive 
to  it.  Patients  who  have  recently  had  those  diseases  in  which 
horse  serum  is  used  as  a  curative  agent,  as  in  diphtheria  anti- 
toxin or  anti-meningococcus  serum,  have  a  peculiar  idiosyncrasy 
to  it,  so  that  if  this  serum  is  given  again,  a  condition  of  "an- 
aphylaxis" may  result. 

Anaphylaxis  has  been  defined  as  "the  increased  susceptibility 
to  an  infection  or  the  action  of  any  foreign  substance  intro- 
duced into  the  body  following  a  primary  infection."  This  con- 
dition is  indeed  serious,  manifesting  itself  by  a  sudden,  labored 
respiration,  rapid  pulse,  cyanosis  and  the  appearance  of  large 
red  cutaneous  blotches,  or  urticaria.  Death  has  been  known 
to  occur  within  a  few  minutes.  If  this  condition  should  re- 
sult, it  is  best  treated  by  the  administration  of  atropine  hypo- 
dermically,  or  adrenalin,  minims  15.  The  elimination  should  be 
further  promoted  by  colon  irrigations. 

Recent  investigations  have  proved  that  patients  with  delayed 
clotting  time  are  often  improved  by  ante-operative  transfusions 
of  human  blood.  The  blood  of  the  patient  should  be  tested 
first  for  the  particular  group  into  which  it  falls,  and  then  a 
transfusion  of  blood  from  a  donor  whose  blood  group  is  the 
same  as  that  of  the  patient  should  be  given.  (This  is  described  in 
Chapter  II.) 


CHAPTER  IV 

THE    SURGERY    AND    SURGICAL    NURSING    OF    THE 
AlilMENTARY   SYSTEM 

Introduction. — In  this  and  the  following  Chapters  V  to  XI 
of  surgical  conditions  involving  the  systems  of  the  body,  the 
various  pre-operative  and  post-operative  nursing  measures  which 
are  peculiar  to  the  individual  case  at  hand  will  be  indicated, 
but  no  standard  routine  courses  of  treatment  can  be  reasonably 
prescribed  because  every  surgeon  will  have  his  own.  These  will 
necessarily  vary  from  time  to  time  in  accordance  with  differ- 
ences in  patients,  operative  procedures,  general  conditions,  etc. 
However,  in  Chapter  XIII,  under  the  subject  of  "Anesthesia," 
and  in  Chapter  XVI,  under  "The  Operating  Room,"  there  are 
recorded  representative  practices  which,  with  what  is  given 
here,  will  give  the  student  the  framework  for  surgical  nursing. 

Before  considering  the  surgery  of  the  Alimentary  System,  a 
brief  review  of  those  organs  which  constitute  it  may  be  instruc- 
tive. 

I.  Organs  of  the  Alimentary  Canal: 

1.  Mouth 

2.  Pharynx 

(1)  Tonsils 

(2)  Adenoids 

3.  Esophagus 

4.  Stomach 

5.  Small  Intestine 

(1)  Duodenum 

(2)  Jejunum 

(3)  Ileum 

6.  Large  Intestine 

(1)  Cecum  and  appendix 

(2)  Colon 

a.  ascending 
h.  transverse 
c.  descending 
38 


NURSING  OF  THE  ALIMENTARY  SYSTEM  39 

(3)  Sigmoid  Flexure 

(4)  Rectum 

(5)  Anus 

II.  AccKSSORY  Organs  op  Digestion  ; 

1.  Teeth 

2.  Tongue 

3.  Salivary  Glands 

(1)  Parotid 

(2)  Submaxillary 

(3)  Sublingual 

4.  Pancreas 

5.  Liver  and  Gall  Bladder 

The  Mouth. — The  mouth  is  of  special  interest  because  it 
comprises  part  of  the  operative  field  of  the  upper  and  lower 
jaws,  and  the  tongue ;  it  is  the  path  through  which  the  tonsils  and 
the  adenoids  are  approached;  and  the  means  by  which  the 
trachea  and  esophagus  are  entered.  Its  main  importance  from 
a  surgical  standpoint  is  that  it  can  never  be  rendered  sterile, 
so  that  all  the  operations  on  the  afore-mentioned  organs  must 
of  necessity  be  contaminated.  Even  though  the  work  is  done 
in  a  contaminated  field,  the  same  aseptic  surgery  should  be  prac- 
tised here  as  is  practised  in  other  regions. 

This  fact  should  not  deter  the  nurse  from  getting  the  mouth 
as  clean  as  possible  for  the  operation.  It  is  usual  to  have  the 
patient  wash  the  buccal  cavity  every  two  hours  with  some 
liquid,  either  warm  saline,  or  water  to  which  has  been  added 
one  of  the  countless  pleasant-tasting  antiseptics  which  are  in 
everyday  use.  This  should  be  begun  about  two  days  prior 
to  the  operation.  It  is  imperative  that  mouth  washing  should  be 
done  thoroughly.  The  nurse  should  not  content  herself  by 
simply  informing  the  patient  that  the  mouth  is  to  be  washed, 
but  she  should  stand  by  and  see  that  it  is  efficiently  done. 
In  addition,  the  teeth  should  be  carefully  brushed  at  least  after 
each  meal.  If  pyorrhea  exists,  the  teeth  should  be  scraped  and 
the  gums  treated  by  a  dentist.  In  this  way  the  amount  of  mouth 
contamination  may  be  reduced  to  the  minimum. 

The  inflammatory  affections  of  the  jaws,  such  as  inflamma- 
tion of  the  gums,  or  gingivitis,  or  pyorrhea  alveolaris,  need 


40  TEXTBOOK  OF  SURGICAL  NURSING 

no  special  meutiou  licre.  But  the  new  growths  of  the  jaws, 
either  benign  or  malignant,  form  a  very  important  chapter  in 
surgery  because  they  may  necessitate  a  resection  of  either  the 
ni^pcr  or  lower  maxilla}. 

Tlie  Jaws. — The  jaw  may  be  the  seat  of  a  varietj^  of  tumor 
formations: — (1)  Cysts  arising  from  some  abnormality  in  the 
development  of  the  teeth;  (2)  non-malignant  growths,  or  epulis; 
and  (3)  malignant  growtlis. 

Treatment  of  New  Growths  of  the  Jaws. — If  the  cysts  are 
small,  they  are  removed  and  the  membrane  wliie-li  lines  the 
cavity  is  destroyed.  If  necessary,  the  cavity  is  packed  and  the 
wound  permitted  to  heal  by  granulation  tissue.  The  only  treat- 
ment is  to  keep  the  mouth  clean. 

In  the  case  of  benign  tumors,  the  tooth  about  which  the  tumor 
grows  is  removed  and  with  it  a  portion  of  the  bone.  The 
removal  is  accomplished  by  a  Gigli  saw.  It  is  always  con- 
venient to  have  at  hand  an  actual  cautery  or  Horsley's  wax 
to  control  the  hemorrhage  which  may  ensue  from  the  bone. 

The  cases  of  malignant  growths,  either  carcinomas  or  sarco- 
mas, demand  radical  operation.  In  the  case  of  the  upper  jaw 
this  is  not  so  practical  because,  Avith  the  removal  of  the  bone, 
the  eyeball  loses  its  support  and  drops  from  its  normal 
anatomical  position  resulting  in '  a  condition  of  double  vision 
or  diplopia ;  and,  by  removing  the  hard  palate,  a  communication 
is  made  between  the  nose  and  mouth.  However,  in  spite  of  these 
two  obstacles,  the  operation  is  occasionally  done. 

The  removal  of  the  lower  jaw,  however,  is  not  so  difficult; 
it  may  be  removed  either  partially  or  in  its  entirety.  The 
actual  operative  technic  is  more  of  interest  to  the  surgeon  than 
the  nurse  and  will  not  be  discussed  here.  The  nursing  pro- 
cedures are  the  same  as  for  any  radical  operation  on  either 
the  upper  or  lower  jaw. 

Ante-operative  Treatment. — As  has  been  mentioned  previ- 
ously, the  mouth  should  be  cleansed  very  carefully.  The  opera- 
tive field,  in  the  male,  should  be  prepared  by  shaving  an  hour 
before  the  operation,  as  the  beard  sometimes  grows  very  rapidly 
and  nothing  is  more  disagreeable  than  to  have  the  patient  enter 
the  operating  room  not  properly  prepared. 


NURSING  OF  THE  ALIMENTARY  SYSTEM  41 

Operation. — The  anesthesia  is  given  by  intratracheal  in- 
sufflation, a  method  whereby  the  vaporized  ether  is  forced  into 
the  trachea  through  a  catheter  by  means  of  a  special  apparatus. 
With  this  method  the  anesthetist  is  removed  far  from  the  opera- 
tive field  and  the  surgeon  is  able  to  work  undisturbed.  The 
head  is  draped  as  is  shown  in  Fig.  82  (page  285).  The  instru- 
ments for  this  operation  are  those  used  for  any  bone  work. 

Post-operative  Treatment. — The  packing,  which  is  intro- 
duced at  operation  into  the  area  vacated  by  the  maxilla,  is 
removed,  as  a  rule,  after  twenty-four  hours.  The  space  left 
by  the  removal  of  the  upper  jaw  should  be  sprayed  through 
the  mouth  every  two  to  three  hours  with  some  antiseptic  solu- 
tion. The  patient,  as  soon  as  he  is  able,  should  wash  his  mouth 
himself  every  two  or  three  hours.  For  the  first  three  days,  it 
is  better  not  to  give  food  by  mouth;  the  nourishment  is  sup- 
plied either  by  nutrient  enemata,  or  by  nasal  gavage,  the  cathe- 
ter being  passed  through  the  nostril  on  the  sound  side.  As 
soon  as  the  wound  granulates,  the  patient  may  be  given  a  liquid 
diet,  the  food  always  being  introduced  along  the  sound  side 
of  the  mouth.  Great  care  should  be  taken  that  the  mouth  be 
thoroughly  cleansed  after  each  feeding.  Some  surgeons  re- 
quest that  the  cavities  be  lightly  packed  with  gauze  during 
feedings  so  as  to  prevent  the  liquid  food  from  entering  the 
operative  wound.  This  is  not  so  important  a  procedure  with 
liquids  as  it  is  with  soft  diet,  which  is  allowed  after  about 
three  weeks.  It  is  unnecessary  to  confine  the  patient  to  bed  any 
longer  than  four  days,  provided  that  everything  goes  smoothly, 
for  needless  confinement  to  bed  often  causes  weakness. 

The  Tongue. — Those  conditions  which  demand  radical  op- 
erative procedure  on  the  tongue  are  invariably  due  to  malignant 
disease,  and  may  require  that  the  tongue  be  removed  in  part, 
halves  or  completely  extirpated.  Removal  of  the  tongue  (glos- 
sectomy)  is  accompanied  by  a  preliminary  removal  of  the  glands 
of  the  submaxillary  triangle  and  a  ligation  of  the  lingual  artery 
which  supplies  the  tongue  with  blood.  By  ligating  this  artery 
before  a  removal  of  the  tongue  is  attempted,  hemorrhage  is  very 
markedly  diminished  at  the  time  of  the  radical  operation. 

Ante-operative    Preparation. — This    consists    of    the    usual 


42  TEXTBOOK  OF  SURGICAL  NURSING 

cleansing  of  the  mouth  as  already  outlmed  in  operations  upon 
the  jaw. 

Operation. — The  anesthetic  is  administered  intranasally. 
The  moiith  is  kept  open  by  a  self-retaining  gag.  A  heavy  silk 
ligature  should  always  be  at  hand  for  introduction  through  the 
base  of  the  tongue.  This  serves  as  a  tractor,  and  even  after 
the  tongue  has  been  removed  the  ligature  is  left  in  place,  the 
free  end  being  fastened  either  to  the  teeth,  or  identified  b}'- 
an  attached  pair  of  forceps  that  liang  from  the  mouth.  This 
ligature  should  remain  in  place  for  at  least  twenty-four  hours 
after  operation,  for  it  is  invaluable  in  controlling  the  base  of 
the  tongue  should  any  serious  hemorrhage  occur. 

Post-operative  Treatment. — In  those  conditions  in  which 
either  half  or  the  entire  tongue  has  been  removed,  the  treat- 
ment of  the  raw  denuded  surface  of  the  floor  of  the  mouth  is 
what  most  concerns  us.  The  desideratum,  of  course,  is  to  ren- 
der this  area  aseptic.  To  attain  this  end,  some  operators  use 
balsam  of  Peru,  which  is  applied  as  gently  as  pos.sible.  The 
dusting  of  iodoform  powder  is  to  be  condemned,  as  iodine  poison- 
ing may  result.  Other  surgeons  prefer  the  use  of  mild  anti- 
septic sprays. 

For  about  four  days,  the  patient  should  be  fed  by  enemata. 
Each  morning  the  bowels  should  be  washed  out  with  a  soap- 
suds enema  followed  by  rectal  feedings  (Chapter  XII)  which 
are  given,  as  a  rule,  every  four  hours.  If  the  patient  is  very 
weak  and  emaciated,  and  demands  more  nourishment  than  can 
be  given  by  rectum,  a  small  stomach  tube  may  be  passed  through 
the  nostril  into  the  stomach,  and  left  in  place.  Some  operators 
prefer  that  the  patient  be  fed  directly  by  mouth;  a  soft  rubber 
catheter  is  passed  along  the  normal  side  of  the  mouth  permitting 
the  patient  to  swallow  the  liquids  which  are  poured  slowly 
through  the  tube.  Each  feeding  should  be  completed  by  the 
administration  of  sterile  water,  and  the  tube  withdrawn,  after 
which  the  mouth  should  be  thoroughly  cleansed.  Soft  diet  may 
be  given  as  soon  as  the  wound  heals  and  swallowing  without 
difficulty  is  possible.  The  patient  should  be  permitted  to  sit 
up  in  bed  as  soon  as  possible,  and  so  as  to  afford  better  drainage 
to  the  secretions  which  collect  in  the  mouth,  the  head  should  be 


NURSING  OF  THE  ALIMENTARY  SYSTEM  43 

kept  bent  slightly  forward.  These  cases  may  be  allowed  up  from 
bed  on  about  the  fourth  day. 

Treatment  of  Inoperable  Cases. — While  all  patients  suffering 
from  inoperable  cancer  are  miserable,  there  are  none  who  pre- 
sent such  a  horrible  spectacle  as  those  with  a  large  f ungating 
growth  of  the  tongue.  Unable  to  swallow,  finding  difficulty  in 
breathing,  suffering  agonies,  with  an  oral  stench  which  is  hardly 
bearable  for  themselves  or  others  associated  with  them,  they 
are  entitled  to  all  the  sympathy  possible.  If  nothing  else  can 
be  done  for  these  unfortunates  they  may  be  kept  absolutely 
free  from  pain.  The  local  pain  is  sometimes  reduced  by  dust- 
ing the  ulcerated  areas  with  orthoform  powder.  It  is  applied 
before  any  food  is  taken.  Morphine  should  be  given  liberally, 
with  a  little  atropine  to  prevent  its  depressing  effects.  The 
foulness  of  the  breath  may  be  lessened  by  the  continual  use 
of  mouth  washes  and  mouth  irrigations.  If  dyspnea  becomes 
marked  because  of  crowding  of  the  larynx  by  growth,  trache- 
otomy may  be  necessary.  If  difficulty  exists  in  swallowing, 
rectal  feeding  may  be  given.  Feeding  by  stomach  tube  or  nasal 
gavage  is  not  practical,  because  the  rubber  tubes  coming  in 
contact  with  the  growths  cause  excruciating  pain.  Occasionally, 
the  proper  use  of  radium  and  X-ray,  in  selected  cases,  will  do 
much  to  give  relief  where  the  knife  of  surgery  has  failed. 

The  Pharynx. — The  pharynx  is  important  surgically  because 
it  lodges  the  tonsils  and  the  posterior  portion  harbors  the  ade- 
noids. As  is  known,  the  tonsils  may  be  the  seat  of  acute  in- 
flammation, and  the  bacteria  may  spread  into  the  surrounding 
tissues  giving  rise  to  what  is  popularly  known  as  a  quinsy  sore 
throat,  or  a  peritonsillar  abscess. 

Treatment  of  a  Peritonsillar  Abscess. — Since  this  condition 
is  in  reality  an  abscess  formation,  means  should  be  taken  to 
cause  a  pointing  of  the  abscess  as  soon  as  possible.  With  this 
ultimate  end,  flaxseed  poultices  should  be  applied  every  two 
hours  to  the  side  of  the  neck  that  is  affected  and  warm  throat 
irrigations  with  a  quart  of  saline  at  105°  should  be  given  at 
regular  intervals.  This  will  not  only  cause  a  localization  of 
the  pus,  but  will  be  very  comforting  to  the  patient  and  re- 
lieve much  of  the  pain  which  accompanies  this  condition.     The 


44  TEXTBOOK  OF  SURGICAL  NURSING 

abscess  is  opened  by  blunt,  incision  under  local  anesthesia  and 
the  pus  evacuated.  The  after  treatment  is  simple,  consisting 
mainly  of  throat  irrigations  and  antiseptic  mouth  washes  to 
relieve  the  oral  fetoi-  and  promote  drainage. 

Tonsillectomy. — Tonsils  are  removed  very  often,  both  be- 
cause of  a  diseased  condit?3n  and  because  of  an  increase  in 
size,  or  hypertrophy.  As  a  rule  the  operation  is  attended  with 
very  little  risk  and  is  performed  nnder  ether  in  cliildren,  and 
wdtli  local  anesthesia  in  adults. 

Operative  Treatment.- — Tlie  patient,  if  a  child,  is  placed  un- 
der ether  anesthesia  in  the  dorsal  position  and  the  mouth  held 
open  by  a  self-retaining  gag;  an  electric  head  lamp  worn  by 
the  surgeon  supplies  the  light.  The  tonsils  are  removed  by  one 
of  several  methods,  either  by  blunt  dissection  with  a  Sinter 
tonsillotome,  or  they  are  dissected  out  with  scissors,  and  finally 
enucleated  with  a  snare.  The  hemorrhage  is  controlled  by  the 
simple  pressure  of  gauze  sponges.  If  necessary,  the  bleeding 
vessels  may  be  tied,  or  a  sponge  with  a  piece  of  tape  securely 
attached  may  be  left  in  the  tonsillar  fossa  for  twenty-four  hours. 
After  the  operation  has  been  completed,  to  further  stop  bleed- 
ing and  cause  the  patient  to  regain  consciousness  as  quickly 
as  possible,  the  neck  and  face  are  bathed  with  towels  previously 
soaked  in  ice  water. 

After  Treatment. — ^While  these  cases  are  apt  to  ooze  a  little 
after  operation,  careful  watch  should  be  kept  on  their  pulse, 
and  if  they  are  bleeding  briskly,  as  evidenced  by  the  constant 
expectoration  of  bright  red  blood,  or  the  vomiting  of  large 
quantitiec  of  altered  blood,  the  attending  surgeon  shoidd  be 
notified  immediately,  for  cases  of  fatal  hemorrhage  have  been 
known  to  result. 

The  diet  should  be  liquid,  ice  cream  being  given  to  children, 
for  the  cold  is  gratifying  to  the  throat,  and  the  psychic  effect 
cheering  to  their  depressed  spirits,  and,  in  addition,  the  cream 
forms  a  protective  layer  to  the  denuded  areas  of  the  pharynx. 
The  patient  is  kept  indoors  for  a  day  or  two  to  prevent  catch- 
ing cold. 

Adenoids. — Adenoids  are  removed  either  with  a  curette  or 


NURSING  OF  THE  ALIMENTARY  SYSTEM  45 

an  adenotome.  This  operation  requires  no  special  treatment 
beyond  that  already  mentioned  for  tonsillectomy. 

The  Esophagus. — While  the  esophagus  is  as  important  as 
any  other  structure  of  the  body,  its  surgery  is  in  its  infancy 
and  the  operations  few  in  number.  Those  diseases  which  in- 
terest the  surgeon  have  very  little  need  for  a  nurse,  since  what- 
ever is  done  in  the  way  of  treatment  is  non-operative  and  per- 
formed by  the  surgeon  himself. 

Diseases  of  the  Esophagus. — The  esophagus  may  be  burned 
by  the  passage  through  it  of  foreign  substances,  or  injured  by 
the  passage  of  foreign  bodies.  This  will  result  in  an  ulceration 
of  the  esophagus,  with  a  resultant  contracture  and  stricture, 
making  swallowing  rather  difficult.  Of  course,  as  in  other  lo- 
cations, cancer  may  elect  the  esophagus,  but  since  it  involves 
this  organ  at  its  lowermost  portion  just  where  it  pierces  the 
diaphragm  muscle,  very  little  is  done  for  it  by  active  surgical 
intervention. 

Treatment. — If  the  esophagus  has  just  been  burned  by  acid, 
then  alkali  must  be  given  in  the  form  of  a  solution  of  sodium 
bicarbonate.  If  caustic  alkali  is  the  agent  which  has  been 
ingested,  then  a  diluted  vinegar  solution  is  given  to  neutralize 
the  base.  The  stricture,  resulting  from  the  healing  of  the  in- 
jured area  of  esophagus  is  treated  by  the  passing  of  esophageal 
sounds,  or  bougies.  These  are  passed  at  frequent  intervals, 
the  diameter  of  the  bougie  being  increased  in  size  until  the 
esophagus  has  been  dilated  to  normal.  If  the  ulceration  is  very 
widespread,  the  dilatation  of  the  esophagus  is  impractical,  and 
because  of  its  extensive  nature,  more  radical  procedures  must  be 
adopted. 

The  patient  being  unable  to  swallow  cannot  be  nourished 
indefinitely  by  rectal  enemata,  so  that  an  opening  must  be  made 
directly  into  the  stomach.  Through  this  fistula  the  food  may 
be  introduced  and  the  patient  receive  the  proper  nourishment 
for  his  existence.  This  operation  is  known  as  gastrostomy 
which  is  described  in  detail  on  page  46. 

Foreign  Bodies  in  the  Esophagus. — The  esophagus,  as  well 
as  the  trachea  and  larynx,  is  often  the  resting  place  for  swal- 
lowed foreign  bodies,  such  as  coins,  pins,  etc.     It  is  very  im- 


46  TEXTBOOK  OF  SURGICAL  NURSING 

portaut  to  really  asoortaiii  that  the  patient  has  a  foreign  body, 
aud  the  X-ray  is  a  valuable  aid  in  determining  the  presence 
of  many  varieties.  Some  of  these  may  be  removed  by  special 
instruments;  for  example,  a  coin-catcher,  or  by  direct  vision 
through  an  esoi^hagoscope.  If  these  bodies  are  of  too  great 
a  size  to  be  easily  dislodged  and  are  caught  fast  in  the  cervical 
region  of  the  esophagus,  the  esophagus  may  be  opened  through 
the  neck,  and  the  object  extracted.  The  operation  is  spoken 
of  as  esophagotomy.  If  the  foreign  body  is  close  to  the  cardiac 
portion  of  the  esophagus  it  may  be  removed  indirectly  via  the 
stomach  by  a  gastrostomy. 

New  Growths  of  the  Esophagus. — While  a  resection  of  the 
esophagus  is  sometimes  performed  for  malignant  stricture,  the 
mortality  is  so  high  and  the  results  so  uncertain  that  con- 
servative rather  than  radical  measures  are  invariably  emploj^ed. 
Most  surgeons  are  content  by  introducing  radium  through  an 
esophagoscope  into  the  esophagus  and  permitting  the  metal  to 
exert  its  rays  upon  the  tumor  cells  and  thus  hinder  their  ex- 
travagant multiplication.  Occasionally  surgeons  perform  a 
gastrostomy^,  so  that  the  patient  will  not  starve  to  death. 

Gastrostomy. — When  the  esophagus  is  narrowed  either  by 
a  benign  stricture,  or  carcinomatous  tissue  to  such  an  extent 
that  feeding  is  practically  imjDossible,  a  gastrostomy  must  be 
performed  to  prevent  the  patient  from  starving.  This  is  an  op- 
eration whereby  a  communication  is  established  betv/een  the 
anterior  surface  of  the  stomach  and  the  anterior  abdominal 
wall.  Through  this  gastric  fistula,  fluid  may  be  introduced,  the 
patient,  in  this  fashion,  being  given  nourishment  without  the 
food  actually  entering  the  esophagus.  There  are  different  types 
of  operations  done  but  they  all  are  essentially  the  same :  they 
vary  in  their  technic. 

Ante-operative  Treatment.^ — The  abdomen  is  prepared  in  the 
usual  manner.  Inasmuch  as  these  patients  are  very  emaciated 
and  weak,  the  operation  is  performed  under  local  anesthesia, 
preliminary^  to  which  morphine  gr.  I/4  with  atropine  gr.  1/150 
is  given  hypodermatically. 

Operation. — The  abdomen  is  opened  by  a  left  rectus  in- 
cision, the  stomach  found,  and  packed  off  from  the  rest  of  the 


NURSING  OF  THE  ALIMENTARY  SYSTEM  47 

abdominal  cavity  with  hot  saline  pads.  A  small  opening  is 
made  into  the  stomach  and  a  sterilized  catheter  is  introduced 
into  its  interior.  The  further  burying  of  the  catheter  within 
the  stomach,  so  as  to  prevent  regurgitation  of  stomach  contents 
through  the  fistula,  is  one  of  technical  detail.  The  peritoneum 
is  then  narrowed  and  a  few  sutures  are  taken  approximating  it 
to  the  stomach,  so  that  this  organ  is  held  firmly  to  the  abdominal 
wall.  The  catheter  is  brought  out  of  the  skin  incision  and 
clamped. 

After  Treatment. — The  patient  is  fed  every  four  hours 
through  the  catheter.  A  convenient  way  of  doing  this  is  to 
connect  it  with  a  small  funnel  so  that  the  fluids  may  be  easily 
poured  into  the  stomach.  The  foods  which  may  be  given  are 
limited  to  those  which  can  be  made  up  into  or  dissolved  in 
fluids,  and  from  six  to  ten  ounces  of  liquids  may  be  given  at 
a  feeding.  Their  caloric  value  should  always  be  estimated  and 
great  care  should  be  taken  to  see  that  the  patient  is  given  suffi- 
cient food.  Some  surgeons  permit  their  patients  to  chew 
solid  food  for  the  taste  and  because  a  flow  of  gastric  juice  is 
stimulated  by  the  hormone  *' secretin"  of  the  saliva;  but, 
naturally,  the  patients  are  not  permitted  to  swallow  the  food. 

After  the  first  few  days  the  catheter  should  be  removed  and 
changed  daily,  a  fresh  clean  one  always  being  ready  for  im- 
mediate insertion.  After  the  feeding  the  end  of  the  tube  should 
be  clamped  so  as  to  prevent  leakage,  and  an  abdominal  binder 
applied.  In  about  two  months'  time  the  tube  may  be  left  out 
of  the  stomach,  and  inserted  at  the  feeding  periods  only.  The 
fistula  in  the  interim  may  be  covered  with  a  piece  of  vase- 
linated  gauze,  held  in  place  by  a  binder.  Patients  should  be 
taught  to  insert  their  own  tubes,  the  method  of  feeding  them- 
selves, and  the  foods  which  may  be  taken. 

It  is  highly  important  that  the  skin  about  a  gastric  fistula 
be  kept  scrupulously  clean.  Should  gastric  contents  leak  either 
from  or  around  the  tube,  the  skin  should  be  washed  immedi- 
ately and  covered  with  some  bland  non-irritating  ointment, 
such  as  Beck's  paste  or  vaseline.  If  this  is  not  done,  the  gastric 
juice  will  digest  the  skin  and  a  painful  ulcerated  area  about 
the  tube  may  result. 


48  TEXTBOOK  OF  SURGICAL  NURSING 

The  Stomach. — The  tiurgery  of  the  stomach  i'oriiLs  one  of 
the  most  brilliant  and  important  chapters  in  general  abdominal 
surgery,  for  each  year  brings  new  gastric  operations  Avith  a  more 
refined  teclmic. 

Operations  upon  the  stomach,  or,  in  fact,  any  part  of  the 
intestinal  tract,  introduce  an  element  which  is  of  great  im- 
portance from  the  standpoint  of  an  operating  nurse.  The 
operative  field  in  a  simple  celiotomy  (the  opening  of  a  peritoneal 
cavity)  is  clean,  and  under  normal  conditions,  free  from  all 
bacteria.  Yet  the  interior  of  the  intestinal  tract  and  colon,  and, 
to  a  slighter  degree,  the  stomach,  are  swarming  with  bacteria. 
Naturally,  in  those  operations  which  necessitate  an  opening 
into  the  stomach,  intestines,  or  colon,  a  previously  clean  field 
will  be  converted  into  a  "dirty"  one.  However,  by  carefully 
padding  off  the  operative  field  from  the  rest  of  the  peritoneal 
cavity,  and  by  later  carefully  discarding  those  instruments 
(needles,  ligatures,  sponges,  towels,  etc.)  which  have  come  into 
contact  with  the  contaminated  field,  it  is  perfectly  possible  to 
maintain  the  sterile  toilet  of  the  peritoneal  cavity.  This  will 
be  discussed  in  greater  detail  subsequently.  And  it  is  upon  the 
nurses  in  the  operating  room  that  this  routine  and  its  observ- 
ances are  partially  dependent. 

Diseases  of  the  Stomach. — The  stomach  may  be  subject  to 
various  inflammations  of  the  mucosa  from  a  variety  of  causes. 
These  are  considered  under  the  general  heading  of  gastritis. 
They  are  of  little  interest  surgically.  The  affections  of  the 
stomach  which  demand  surgical  treatment  are  those  of  gastric 
ulcer  and  gastric  carcinoma. 

Gastric  Ulcer. — Gastric  ulcer  starts  as  an  erosion  of  the 
mucosa  of  the  stomach,  the  ulceration  gradually  extending 
deeper,  at  times  eating  its  way  through  the  muscular  and  serous 
coats  of  the  stomach  causing  a  communication  between  the  in- 
terior of  the  stomach  and  the  general  peritoneal  cavity.  The 
ulcer  in  itself  is  not  so  serious  but  by  growing  it  may  open  a 
blood  vessel,  causing  a  gastric  hemorrhage  (hematemesis).  Or 
the  scar  tissue  which  follows  in  the  path  of  a  healing  ulcer  may 
interfere  with  the  gastric  functions  by  creating  various  de- 
formities of  the  stomach.    This  is  especially  true  when  the  ulcer 


NUESING  OF  THE  ALIMENTARY  SYSTEM  49 

occurs  in  the  region  of  the  pylorus;  subsequent  healing  of  an 
ulcer  in  this  location  may  result  in  a  narrowing  or  stenosis 
of  the  pyloric  orifice.  The  third  danger  already  mentioned  is 
that  of  perforation,  through  which  the  gastric  contents  are 
emptied  into  the  general  peritoneal  cavity  resulting  in  a 
peritonitis. 

The  symptoms  of  gastric  ulcer,  in  brief,  are  epigastric  pain, 
vomiting,  and  bleeding.  Although  the  last  is  one  of  the 
most  persistent  signs  of  gastric  ulcer  it  may  be  absent.  Exami- 
nation of  the  stomach  contents  may  show  an  increase  in  the 
amount  of  free  hydrochloric  acid  and  the  presence  of  blood. 
X-ray  examination  with  a  bismuth  meal  may  reveal  an  irregu- 
larity in  the  outline  of  the  stomach,  indicative  of  ulcer. 

Treatment  of  Gastric  Ulcer. — The  treatment  is  both  medical 
and  surgical.  The  latter  only  will  be  discussed  here.  Surgical 
treatment  is  employed  w^hen  (1)  medical  treatment  has  given 
little  relief,  (2)  when  perforation  of  the  ulcer  has  occurred, 
(3)  -when  perforation  has  resulted  in  the  formation  of  an  ab- 
scess, or  (4)  when  the  pylorus  has  become  stenosed. 

The  treatment  of  the  chronic  cases  is  to  short-circuit  the  food 
contents  from  the  stomach  to  the  jejunum  directly,  instead  of 
first  passing  through  the  pyloris  and  duodenum.  This  will  per- 
mit the  ulcer  to  heal  by  giving  the  pyloric  portion  of  the  stom- 
ach a  functional  rest ;  and,  in  those  cases  of  pyloric  constric- 
tion, the  food  will  now  have  a  free  exit  through  the  new  opening. 
The  establishment  of  a  new  opening  in  the  stomach  aad  attach- 
ment to  it  of  the  intestine  is  known  as  gastroenterostomy.  The 
jejunum  may  be  attached  to  either  the  anterior  or  posterior 
surface  of  the  stomach,  resulting  in  either  an  anterior  or  pos- 
terior gastrojejunostomy. 

Gastroenterostomy. — Ante-operative  Treatment. — In  chronic 
cases  of  ulcer  of  the  stomach  prior  to  the  time  of  operation,  fluid 
should  be  forced  upon  the  patient  so  that  there  will  be  a  re- 
serve amount  in  the  tissues.  An  hour  before  operation  the 
stomach  is  washed.  Great  care  should  be  taken  that  the  return 
flow  is  absolutely  clear  at  the  completion  of  the  treatment  and 
that  none  of  the  lavaging  fluid  is  left  within  the  viscus. 

Operative  Treatment. — The  operation  itself  will  be  briefly 


50  TEXTBOOK  OF  SURGICAL  NURSING 

outlined  demonstrating  the  manner  in  which  the  sterility  of 
the  peritoneal  cavity  can  be  maintained  although  the  stomach 
and  jejunum  have  been  opened  and  the  field  contaminated. 
After  the  skin  incision  has  been  made,  some  surgeons  clamp 
sheets  to  the  subcutaneous  tissues.  The  incision  is  then  deep- 
ened through  the  fascia  and  muscles,  the  peritoneum  opened,  and 
the  stomach  and  the  jejunum  delivered  into  the  wound.  The 
jejunum  is  stripped  free  of  its  fecal  content,  and  an  intestinal 
clamp  with  rubber-covered  blades  applied  lengthwise.  The 
stomach  is  clamped  in  a  similar  manner.  The  immediate  opera- 
tive field  is  padded  off  with  hot  gauze  pads  and  the  surround- 
ing sheets  are  further  protected  with  additional  towels.  The 
stomach  and  jejunum  are  then  brought  into  proximity  by  an 
approximating  Gushing  suture,  using  Pagenstecher  linen  thread 
on  a  straight  round  needle.  This  suture  should  be  sufficiently 
long  to  completely  encircle  the  stoma  between  the  stomach  and 
intestines.  The  needle  and  thread  are  protected  with  gauze 
for  the  time  being.  The  stomach  and  intestine  are  now  ready 
to  be  opened.  From  now  on  until  a  sterile  field  is  reestab- 
lished everything  contaminated  from  contact  with  the  open  gut 
should  be  placed  on  a  tray  provided  for  dirty  instruments.  The 
surgeon  and  his  assistants  must  not  touch  anything  on  the 
clean  instrument  table,  and  the  sterile  nurse  must  avoid  touch- 
ing with  her  gloved  hands  anything  that  has  come  into  con- 
tact with  the  contaminated  operative  field.  After  the  redundant 
mucous  membrane  has  been  trimmed,  the  mucous  coat  of  the 
stomach  is  ready  to  be  united  to  the  contiguous  mucous  coat 
of  the  jejunum.  This  is  accomplished  with  through-and-through 
lock  stitch  using  number  0  or  1  chromic  catgut  on  a  round 
straight  needle  for  one-half  the  circumference  of  the  opening, 
a  through-and-through  Gushing  stitch  completing  the  closure. 
The  contaminated  field  is  now  sealed  off ;  clamps,  soiled  gauze 
pads,  instruments  and  towels  are  removed  and  the  gloves  of  the 
surgeon  and  his  assistants  are  either  washed  in  bichloride  or 
exchanged  for  a  new  pair.  The  suture  line  is  cleansed  with 
saline  solution  and  fresh  pads  reapplied.  The  suture  is  re- 
enforced  with  Gushing  suture  of  Pagenstecher  linen  thread, 
as  a  continuation  of  the  original  approximative  linen  suture. 


NURSING  OF  THE  ALIMENTARY  SYSTEM  51 

After  the  opening  of  the  transverse  mesocolon  has  been  sutured 
around  the  union  between  the  stomach  and  the  jejunum  with 
interrupted  number  1  plain  catgut  on  a  round  curved  needle, 
the  gut  is  washed  with  saline  solution  and  fresh  towels  placed 
about  the  operative  field.  The  hands  are  again  washed  with 
bichloride,  the  gut  returned  into  the  peritoneal  cavity  and  the 
abdomen  closed. 

This  will  give  an  idea  of  the  great  care  which  must  be 
taken  throughout  the  operation  to  maintain  strict  asepsis,  and 
the  nurse  must  be  ever  on  the  alert  to  see  that  the  technic  is 
rigidly  followed. 

After  Treatment. — There  is  some  degree  of  shock  following 
this  type  of  operation,  and  it  is  necessary  to  administer  saline 
hypodermatically,  or  by  rectum  by  Murphy  drip.  The  drip 
should  be  kept  on  for  about  four  hours  and  off  for  two.  This 
will  prevent  irritability  of  the  rectal  mucosa,  and  insure  the 
proper  absorption  of  the  fluid.  But  as  soon  as  the  patient  is 
receiving  sufficient  nourishment  by  mouth  the  drip  may  be  dis- 
continued. 

"When  the  patient  has  recovered  from  the  anesthesia,  he 
should  be  placed  in  Fowler's  position  (page  59),  for  this  posi- 
tion favors  the  passage  of  the  ingested  food  through  the  new 
opening,  the  gastroenterostomy  stoma.  Some  surgeons  are  in 
the  habit  of  allowing  fluids  within  a  few  hours  after  the  anes- 
thetic nausea  and  vomiting  have  disappeared.  Water  is  given 
in  dram  doses  every  hour,  and  if  it  is  tolerated,  after  a  few 
feedings  an  ounce  of  peptonized  milk  is  allowed  every  two 
hours,  alternating  with  water  every  two  hours.  This  may  be 
followed  on  about  the  second  or  third  day  by  an  ordinary  Len- 
hartz  diet.  In  some  hospitals,  a  special  gastroenterostomy  diet 
has  been  arranged  for  these  patients.  Outlines  of  these  diets 
will  be  found  in  Chapter  XII. 

Complications  after  Gastroenterostomy. — Hemorrhage. — Oc- 
casionally, after  the  operation,  the  pulse  may  mount  in  fre- 
quency and  the  patient  exhibit  all  the  clinical  symptoms  of 
hemorrhage.  This  is  evidence  of  gastric  bleeding.  The  patient 
should  immediately  be  placed  in ,  an  upright  position  in  bed, 
and  cold  applied  over  the  upper  epigastrium  by  ice  bags,  ice 


52  TEXTBOOK  OF  SURGICAL  NURSING 

coils  or  cold  compresses.  Cold  may  be  applied  internally  by 
permitting  the  patient  to  swallow  small  pieces  of  cracked  lee. 
Adrenalin  liytlroclilor'ule,  1-1000  may  be  given  in  saline  solu- 
tion by  moutli  to  control  the  bleeding  for  its  local  action  as  a 
vasoconstrictor  is  well  known,  and  at  times  it  is  a  very  efficient 
hemostatic. 

Vomiting. — In  spite  of  the  fact  that  an  operation  has  been 
performed  upon  the  stomach  itself,  the  surgeon  will  order  a 
gastric  lavage  eighteen  to  twenty-four  hours  after  operation  if 
the  vomiting  is  persistent;  this  may  be  repeated  as  often  as  is 
necessary. 

Perforated  Gastric  Ulcer. — Ante-Operative  Treatment. — 
Patients  sutfering  from  a  perforation  of  a  gastric  ulcer  have,  as 
a  rule,  a  beginning  peritonitis,  and  as  they  are  more  or  less 
in  a  condition  of  shock,  it  is  advisable  that  before  operation  ^4 
grain  of  morphine  be  given  hypodermically.  This  will  relieve  to 
a  degree  some  of  the  intense  cramp-like  pains  and  will  make  the 
inductive  stage  of  anesthesia  smoother  so  that  the  struggling  is 
less.  If  they  are  in  a  state  of  severe  shock,  a  preliminary  in- 
fusion of  about  550  c.c.  of  saline  should  be  given. 

Operation. — The  abdomen  is  opened,  the  region  about  the 
stomach  carefully  padded  off:  with  moist  hot  pads  and  the  per- 
foration hunted  for.  When  found,  if  practical,  it  is  enclosed 
and  inverted  with  a  purse  string  suture.  A  thorough  lavage  of 
that  region  of  the  peritoneal  cavity  is  performed  by  washing  out 
the  upper  abdomen  with  warm  saline,  sponging  out  the  saline 
or  using  an  aspirator  attached  to  a  suction  machine.  Some  op- 
erators are  accustomed  to  leave  500  c.c.  of  saline  in  the  abdomen 
before  closing.  The  question  of  drainage  is  left  to  the  dis- 
cretion of  the  individual  surgeon. 

Post-operative  Treatment. — As  soon  as  possible  the  patient 
is  placed  in  the  Fowler  position,  and  if  greatly  shocked  a  clysis 
is  given,  of  500  to  750  c.c.  of  saline.  Some  prefer  the  admin- 
istration of  saline  by  rectum,  given  by  Murphy  drip,  four  hours 
on  and  two  hours  off.  Feeding  is  begun  after  eight  to  twenty- 
four  hours,  and  the  patient  may  be  placed  upon  a  Lenhartz 
diet.  As  a  matter  of  fact,  treatment  for  this  condition  is  almost 
the  same  as  that  for  a  gastroenterostomy. 


NURSING  OF  THE  ALIMENTARY  SYSTEM  53 

Cancer  of  Stomach. — The  symptoms  of  wliich  the  patient  will 
complain  are  determined  by  the  area  in  which  the  growth  is 
located.  If  it  is  near  the  cardiac  end  where  it  does  not  inter- 
fere with  the  functions  of  the  stomach  there  may  be  no  symptoms 
at  all.  If  it  is  in  the  fundus  of  the  stomach  there  may  be  pain, 
vomiting,  loss  of  weight  and  anemia.  If  it  is  in  the  pyloric 
portion,  these  symptoms  are  duplicated  and  there  is  a  greater 
tendency  to  vomit  because  of  the  obstruction.  Examination 
of  the  stomach  contents  in  these  cases  may  reveal  a  low  acid 
content,  no  free  hydrochloric  acid,  and  often  the  presence  of 
lactic  acid.  X-ray  examination  is  sometimes  a  valuable  aid  to 
diagnosis,  and,  occasionally,  the  tumor  mass  may  be  felt  in 
the  upper  abdomen  in  the  position  of  the  stomach. 

Surgical  Treatment  of  Cancer  of  Stomach.-^The  only  hope 
in  cases  of  gastric  cancer  is  partial  or  complete  excision  of  the 
stomach  (gastrectomy).  The  operation  is  rather  shocking  and 
the  mortality  is  high.  The  technic  for  operation  and  the  post- 
operative care  are  practically  the  same  as  that  already  described 
in  the  treatment  of  gastric  ulcer. 

Treatment  of  Duodenal  Ulcer. — This  is  practically  the  same 
as  the  treatment  for  gastric  ulcer. 

Surgical  Conditions  of  Intestines. — There  are  many  diseases 
affecting  the  intestines  but  the  interesting  ones  from  a  surgi- 
cal standpoint  are  those  resulting  in  perforations  and  new 
growths.  The  intestines  may  be  the  seat  of  perforation  as  the 
result  of  typhoid,  or  tuberculous  ulcers,  or  they  may  be  torn 
by  some  traumatic  condition  resulting  from  a  stab  or  bullet 
wound.  The  symptoms  are  those  of  peritonitis.  The  operation 
at  first  is  in  the  nature  of  an  exploratory  laparotomy.  A  search 
is  made  for  the  injured  intestine  and  when  found  the  wound, 
if  small,  is  closed  by  a  purse  string  suture.  If  the  wounds  are 
multiple,  it  may  be  necessary  that  that  part  of  the  intestine 
be  resected,  and  the  two  open  ends  of  the  gut  which  have  re- 
sulted may  then  be  joined  together  by  what  is  known  as  an  end- 
to-end,  end-to-side,  or  side-to-side  anastomosis  (Fig.  6,  A,  B, 
&  C).  Resection  is  also  employed  in  conditions  of  intestinal 
growths,  either  benign  or  malignant. 

If  the  condition  of  the  patient  is  too  poor  to  warrant  the 


54 


TEXTBOOK  OF  SURGICAL  NURSING 


time  necessary  to  anastomose  the  intestines  -with  suture,  a  Mur- 
phj^  button  may  be  employed  (Fig.  6,  D),  This  is  a  perforated 
metal  button  consisting  of  two  halves.  One  half  is  introduced 
into  one  ojien  end  of  the  intestine  and  the  intestine  drawn  over 
it  by  suture.  The  other  half  is  inserted  into  the  other  open 
end  of  the  gut.  The  two  parts  of  the  button  are  then  locked 
together,  thus  anastomosing  the  walls  of  the   intestine.     The 


Fig.  6. — Types  of  Intestinal  Anastomoses.     A,  end  to  end;  B,  side  to 
side;  C,  end  to  side;  D,  end  to  end  by  Murphy  button. 


button  eventually  passes  along  the  intestine  after  the  union 
between  the  bowel  segments  has  become  firm. 

Post-operative  Treatment. — Operations  upon  the  intestines 
require  the  same  care  practically  as  that  folloAving  operations 
upon  the  stomach,  except  that  cathartics  by  mouth  should  not  be 
given  too  early,  and,  when  one  is  given,  a  mild  cathartic  rather 
than  a  severe  purgative  should  be  prescribed.  While  the  pa- 
tient should  be  kept  free  from  pain,  too  much  morphine  should 
not  be  administered,  for  there  is  always  danger  of  intestinal 
paresis  due  to  overdosage  of  this  powerful  hypnotic.     Should 


NURSING  OF  THE  ALIMENTARY  SYSTEM  55 

the  patient  become  distended,  an  irritative  enema  should  be  ad- 
ministered, and  after  the  fourth  day  coh)n  irrigations  may 
be  employed  without  any  danger.  If  a  Murphy  button  has 
been  used  for  anastomosis,  all  stools  should  be  examined  for  the 
presence  of  the  button,  and  its  passage  should  be  immediately 
reported. 

Intestinal  Obstruction. — This  is  a  condition  in  which  the 
normal  passage  through  the  intestinal  tract  is  interfered  with, 
either  partially  or  completely.  The  symptoms  naturally  will 
vary  according  to  the  locality  of  the  obstruction.  If  it  is  high 
up,  near  the  duodenum,  vomiting  is  an  early  symptom;  if  low 
in  the  ileum,  distention  is  more  marked. 

Treatment. — Immediately  after  a  diagnosis  of  intestinal  ob- 
struction, an  exploratory  celiotomy  is  performed  with  the  hope 
of  finding  the  cause  of  the  obstruction  and  relieving  it. 

Ante-operative  Treatment. — In  all  cases  of  intestinal  ob- 
struction it  is  very  essential  that  the  stomach  be  washed  just 
before  giving  the  anesthetic.  This  will  save  a  great  deal  of 
annoyance  later,  because  the  danger  of  aspirating  the  foul  ma- 
terials stored  in  the  stomach  is  reduced  to  the  minimum.  If 
the  patient  is  very  weak  or  greatly  shocked  it  is  advisable  to 
adininister  the  clysis  of  saline  either  before  the  operation  or  at 
the  same  time  the  operation  is  being  performed. 

Operation. — Inasmuch  as  the  actual  surgical  conditions  in 
most  cases  of  intestinal  obstruction  are  not  diagnosed  until 
the  operation,  the  operating  room  nurse  should  be  ready  at 
a  moment's  notice  for  anything  from  an  enterostomy  to  an  ex- 
tensive resection.  Since  these  operations  demand  a  complete 
exploration,  there  should  always  be  on  hand  plenty  of  pads 
and  hot  saline  to  care  for  the  intestines  as  they  are  brought  out 
from  the  peritoneal  cavity.  If,  after  the  obstructive  element 
has  been  found  and  removed,  the  distention  is  still  great  to  the 
point  of  paralysis  of  the  smooth  muscle  of  the  intestine,  an 
enterostomy  might  be  performed.  This  is  an  incision  into  the 
bowel  for  the  purpose  of  inserting  therein  an  L-shaped  glass 
tube  known  as  a  Paul's  tube,  or  a  simple  rubber  one.  The  open 
end  of  the  glass  is  connected  with  rubber  tubing  which  drains 
into  a  bottle  provided  for  the  escape  of  the  intestinal  contents. 


56  TEXTBOOK  OF  SURGICAL  NURSING 

This  operation  practically  amounts  to  the  formation  of  an  arti- 
ficial anus. 

Post-operative  Treatment. — If  an  enterostomy  has  been 
done,  the  treatment  is  the  same  as  that  prescribed  following 
intestinal  injuries.  If  the  tube  has.  been  placed  in  a  high  por- 
tion of  the  jejunum,  peptonized  milk,  beaten  egg  and  other  nu- 
tritive fluids  may  bo  introduced  through  it  via  a  catheter  enter- 
ing the  descending  loop  of  gut ;  the  original  enterostomy  tube 
should  be  temporarily  clamped  after  the  feeding  has  been  intro- 
duced. It  is  very  important  that  these  cases  should  be  given 
plenty  of  fluid  either  hypodermically,  rectally,  or  by  infusion. 
The  skin  about  the  enterostomy  opening  should  be  well  protected 
against  the  irritating  influences  of  the  intestinal  contents  either 
by  albolinated  gauze  or  Beck's  paste. 

Intussusception. — This  condition  is  a  form  of  intestinal  ob- 
struction brought  about  by  the  telescoping  of  one  portion  of 
the  bowel  into  the  other.  The  treatment,  as  a  rule,  is  operative 
entailing  a  reduction  of  the  intussusception,  or  if  the  bowel  is 
gangrenous,  a  resection  of  the  involved  poi-tions.  There  is 
nothing  special  in  its  nursing. 

Appendicitis. — This  is  one  of  the  most  common  operations 
performed  today,  and  the  cases  in  which  the  nurse  will  be  called 
upon  to  assist  may  be  divided  into  three  great  groups. 

1.  Interval  or  Chronic  Appendicitis. 

2.  Acute  Appendicitis  without  perforation. 

3.  Acute  Appendicitis  with  perforation, 

1.  The  Interval  Appendix. — This  is  called  an  interval  ap- 
pendix because  the  operation  is  performed  after  an  acute  attack 
has  passed  away  and  before  another  acute  attack  makes  its 
appearance.  In  other  words,  it  is  an  acute  appendix  which  has 
subsided,  or  has  become  what  may  be  termed  a  chronic  appendix. 

Symptoms. — These  may  vary  tremendously  from  vague  di- 
gestive disturbances  manifested  by  gaseous  eruptions,  pain  and 
flatulence,  to  definite  pain  localized  in  the  right  lower  quadrant, 
the  usual  anatomical  position  of  the  appendix. 

Treatment. — After  a  definite  diagnosis  has  been  made,  the 
appendix  is  removed.    The  operation  is  termed  appendicectomy. 

Ante-operative     Treatment. — The     routine     ante-operative 


NURSING  OF  THE  ALIMENTARY  SYSTEM  57 

preparation  which  is  described  in  Chapter  XIII  is  given.  The 
operation  is  done  under  gas  and  oxygen,  or  gas  and  ether,  or 
it  may  be  done  under  local  anesthesia. 

Operation. — The  abdomen  is  usually  opened  by  a  "Mc- 
Burney"  or  oblique  incision,  or  a  right  rectus,  or  a  vertical 
incision.  The  appendix  is  usually  delivered  into  the  wound, 
the  mesentery  is  ligated  with  plain  catgut  and  a  purse  string 
suture  of  linen  or  Pagenstecher  on  a  straight  or  curved 
needle  is  introduced  about  the  base  of  the  appendix ;  the  base 
is  doubly  clamped  or  ligated  and  a  split  pad  placed  about  both 
clamps.  The  appendix  is  then  cut  between  the  clamps  or  liga- 
tures by  means  of  a  knife  dipped  in  carbolic  acid  or  by  actual 
cautery.  For  safety's  sake,  the  stump  is  again  cauterized  or 
carbolized.  If  the  latter  procedure  is  used,  it  is  neutralized 
with  alcohol  to  prevent  the  carbolic  from  eating  too  deeply.  All 
the  instruments  coming  into  contact  with  the  lumen  of  the 
appendix  are  contaminated  and  should  be  placed  in  a  separate 
''dirty  "  tray.  The  clamp  is  then  removed ;  the  cauterized  stump 
is  grasped  with  a  small  pair  of  forceps  and  buried  by  means  of 
a  purse  string  suture.  The  hands  are  then  washed  in  bichloride, 
the  towels  changed,  and  a  reinforcing  figure-of-eight  suture  may 
be  taken.     The  abdomen  is  then  closed  in  the  usual  manner. 

Post-operative  Treatment. — The  patient  is  given  a  quarter 
of  a  grain  of  morphine  and  1/150  grain  of  atropine,  if  neces- 
sary. As  soon  as  the  patient  regains  consciousness  the  gatch 
is  raised  one  notch.  Water  is  allowed  in  sips  about  two  hours 
after  the  last  vomiting,  and  the  usual  post-operative  routine 
begun.  The  sutures  are  generally  removed  on  the  seventh  day, 
and  the  patient  alloM^ed  out  of  bed  on  the  ninth.  The  bowels  are 
moved  on  the  second  or  third  day  by  a  dose  of  salts,  followed 
by  an  enema,  if  necessary. 

Acute  Appendicitis. — Rutherford  Morrison  states  that  there 
would  be  no  percentage  of  deaths  from  appendicitis  if  every 
case  commencing  with  acute  pain  and  developing  tenderness 
and  rigidity  of  the  abdomen  in  the  right  lower  quadrant  with 
a  quickening  of  the  pulse  were  operated  upon  within  twelve 
hours.  This  fact  is  of  great  importance.  It  is  hard  to  impress 
it  upon  the  lay  mind,  but  it  is  the  duty  of  the  nurse  to  instruct 


58  TEXTBOOK  OF  SURGICAL  NURSING 

the  public  upon  this  subject.  Sudden  pain  in  the  right  iliac 
fossa  with  tenderness  and  slight  fever  accompanied  by  nausea 
or  vomiting  point,  as  a  rule,  to  acute  appendicitis. 

Treatment  of  Acute  Appendicitis. — While  most  surgeons  are 
agreed  tliat  all  cases  of  acute  appendicitis  should  be  operated 
upon  as  soon  as  the  diagnosis  is  made,  there  are  some  patients 
who,  in  spite  of  all  persuasion,  refuse  immediate  operation. 
Then  again,  when  there  is  extensive  pulmonary  tuberculosis, 
bad  cardiovascular  disease,  or  diabetes,  the  expectant  treatment 
might  be  followed.  Of  course  this  is  dangerous.  The  family 
should  be  warned  of  the  consequences,  and  the  patient  carefully 
watched.  Blood  counts  should  be  taken  often,  and  should  the 
pulse  rate  and  the  number  of  white  blood  cells  increase,  although 
the  temperature  does  not  vary,  an  operation  should  be  per- 
formed, even  if  local  anesthesia  has  to  be  resorted  to.  If  the 
non-operative  treatment  is  to  be  pursued,  the  patient  should  be 
put  to  bed,  the  knees  flexed  with  a  pillow  underneath  them  and 
ice  bags  applied  to  the  abdomen.  The  bag  should  be  left  on  for 
two  hours-  and  off  for  one.  Nothing  should  be  given  by  mouth 
while  there  is  vomiting.  After  the  nausea  has  subsided,  water 
may  be  given  in  teaspoonful  doses.  This  may  be  augmented 
later  by  albumen  water,  milk  and  lime  water,  broths  and  meat 
juices.  Enemas  should  not  be  given  promiscuously^,  and  if  at 
all,  in  small  amounts  and  with  great  care.  When  the  acute 
symptoms  have  subsided  a  saline  cathartic  may  be  given  by 
mouth. 

Ante- operative  Treatment. — Fortunately,  most  of  these  cases 
are  generally  operated  upon  as  soon  as  the  diagnosis  is  made. 
Naturally  no  cathartic  is  ever  given  by  mouth,  but,  if  the  patient 
is  in  good  condition,  the  lower  bowel  may  be  cleaned  by  a  soap- 
suds enema.  This  does  much  to  render  post-operative  recovery 
smooth  and  uneventful. 

Operation.-  -The  procedure  is  the  same  as  that  in  interval 
appendicitis  and  if  the  appendix  has  not  ruptured,  the  abdomen 
is  sewed  tightly  without  drainage. 

Post-operative  Treatment. — The  treatment  is  identical  with 
that  prescribed  for  interval  appendicitis,  except  that  occasionally 
eight  ounces  of  tap  water  might  be  administered  by  rectum  and 


NURSING  OF  THE  ALIMENTARY  SYSTEM  59 

the  patient  ordered  in  Fowler's  position  if  there  was  free  fluid  in 
the  pelvis.  (The  Fowler  position  is  a  semi-erect  position  obtained 
by  either  elevating  the  head  of  the  bed  and  flexing  the  knees 
with  a  pillow  or  by  adjusting  the  gatch  bed.)  A  cathartic  is 
generally  given  on  the  third  or  fourth  day.  If  everything  pro- 
gresses smoothly  the  patient  is  allowed  up  on  the  ninth  day. 

Acute  Appendicitis  with  Perforation. — This  is  a  condition  of 
acute  appendicitis  complicated  by  a  perforation  which  either 
forms  an  abscess  about  the  appendix  or  results  in  a  diffuse 
spreading  infection  of  the  peritoneum  (peritonitis).  The 
symptoms  are  those  of  acute  appendicitis,  only  more  severe. 

Ante-operative  Treatment. — The  treatment  is  the  same  as 
that  which  has  been  outlined  for  acute  appendicitis. 

Operative  Treatment. — The  appendix  is  removed  and  the 
stump  inverted  whenever  possible.  The  abscess  cavity  is  freed 
of  its  pus,  and  a  drain  is  introduced  into  the  cavity  or  into 
the  lower  pelvis.  The  drainage  material  may  be  any  one  of 
the  substances  discussed  on  page  310,  Chapter  XVII. 

Post-operative  Treatment. — The  treatment  is  similar  to  that 
of  acute  appendicitis,  except  that  the  patient  is  usually  more 
■acutely  ill,  and  occasionally  shocked.  The  patient  is  placed  in 
Fowler's  position  and  saline  is  given  liberally  by  Murphy  drip. 
Dressings  are  generally  done  daily.  The  patient  is  kept  in  bed 
until  the  drainage  tube  has  been  removed  and  the  wound  is  prac- 
tically healed. 

Complications. — The  complications  apt  to  occur  are  those 
which  follow  any  abdominal  operation  for  peritonitis.  Those 
cases  in  which  there  is  a  persistently  high  temperature  and  an 
increased  leukocyte  count  should  make  one  suspect  a  secondary 
abscess.  If  a  mass  is  felt  through  the  rectum,  definite  proof 
of  a  secondary  pelvic  abscess  is  established.  This  condition 
does  not  always  demand  operation  to  establish  drainage  of  the 
abscess,  as  in  some  cases  the  mass  might  be  absorbed  by  efficient 
hot  colon  irrigations  given  at  four-hour  intervals. 

Occasionally  a  dressing  which  has  been  previously  pussy,  may 
be  covered  with  blood.  This  is  evidence  of  a  secondary  hem- 
orrhage.    The  attending  surgeon  should  be  called  without  any 


60  TEXTBOOK  OF  SURGICAL  NURSING 

loss  of  time,  and  tlie  wound  packed  temporarily  to  control  the 
bleeding.     The  bleeding  vessel  is  then  sought  and  ligated. 

Now  and  then,  quite  soon  after  operation,  the  dressing  may 
be  covered  Avith  feces;  a  sign  that  the  dreaded  complication  of 
fecal  fistula  has  occurred.  All  drainage  tubes  are  removed,  and 
the  wound  is  treated  as  any  enterostomy  or  colostomy.  Dressings 
are  changed  at  frequent  intervals,  and  the  skin  is  protected  and 
kept  scrupulously  clean.  Fortunately,  most  of  these  cases  heal 
eventually,  although  convalescence  is  long  and  protracted. 

Recentl}'^,  cases  of  appendicular  abscesses  have  been  treated 
by  the  Carrel-Dakin  method.  The  tcchnic  of  its  administration 
is  described  in  Chapter  XIX. 

The  Colon. — AVithin  recent  years  the  surgery  of  the  colon 
has  made  tremendous  strides  because  of  the  attention  drawn  to 
it  by  the  much  discussed  topic  of  colonic  stasis  and  its  relation- 
ship to  autointoxication.  While  many  of  the  English  surgeons 
excise  the  colon  in  cases  of  obstinate  and  obdurate  constipation, 
complete  or  partial  colectomy  is  done  mainly  for  new  growths 
of  the  large  intestine.  In  certain  types  of  cases  where  an  arti- 
ficial anus  has  to  be  established  as  a  preliminary  measure, 
colostomy  is  done,  or  the  colostomy  may  be  the  only  advisable 
palliative  measure  for  inoperable  carcinoma.  The  surgery  and 
nursing  entailed  for  colon  cases  is  practically  the  same  as  that 
for  the  intestinal  variety  both  from  the  ante-operative  and  the 
operative  standpoint.  The  only  difference  is  found  in  the  post- 
operative treatment ;  all  rectal  medication  should  be  omitted  for 
as  great  a  period  as  is  possible. 

Colostomy. — A  colostomy  is  an  incision  into  the  colon  for 
the  purpose  of  short-circuiting  the  fecal  contents  and  of  estab- 
lishing an  artificial  anus.  The  operation  of  colostomy  is  simple. 
The  desired  part  of  the  colon  is  brought  into  the  wound,  then  a 
glass  tube  is  passed  through  the  mesentery  of  the  colon,  so  as 
to  prevent  the  colon  from  slipping  back  into  the  peritoneal  cavity. 
(Fig.  7.)  The  exposed  colon  is  then  sealed  off  from  the  peritoneal 
cavity  by  suturing  it  to  tlie  parietal  peritoneum. 

Post-operative  Treatment. — The  colon  is  covered  with  vase- 
linated  gauze,  and  a  sterile  dressing  applied.     The  patient  is 


NURSING  OF  THE  ALIMENTARY  SYSTEM 


61 


---£> 


----'/^ 


\ 


y 


fed  but  little  and  to  further  constipate  the  patient  a  pill  of 

opium,  grains  2,  may  be  given  for  the  first  four  or  five  days. 

On  about  the  third  or  fourth  day  the  exposed  loop  of  colon  is 

opened   with   the   aid   of   an 

actual    cautery,    establishing  y^^-^ 

the  artificial  anus.  There  are 

several    factors   that    are   of 

importance  in   caring   for   a 

patient  with  a  colostomy.     If 

possible,    an   attempt   should 

be  made  to  regulate  the  move- 
ment of  the  bowels  and  the 

food   given    should   be    of    a 

constipating  variety,  so  that 

when    the   bowels   move,    the 

movement     should    be    hard 

and  formed,  instead  of  loose 

and  diarrheal.    The  skin  sur- 
rounding   the     colostomy    is 

apt  to  become  irritated.     It 

.should   be    protected   by    an 

ointment  of  bismuth  subnitrate  and  zinc  oxide  to  which  may  be 

added  a  little  oil  of  eucalyptus. 

If  at  any  time,  however,  there  is  no  movement  from  the  arti- 
ficial anus,  and  general  distention  is  evident,  there  should  be 
no  hesitancy  in  giving  an  enema  through  the 
colostomy  opening.  It  is  not  advisable  to 
give  cathartics  by  mouth,  espeeiall}"  the  saline 
variety,  for  it  should  alw^a^'s  be  remembered 
that  these  patients  have  practically  no  con- 
trol of  their  bowel  movements,  and  watery 
stools  cause  a  constant  soiling  of  their  dress- 
ings. After  a  while  the  patient  may  wear 
a  colostomy  bag,  a  rubber  appliance  which  is 

worn  over  the  artificial  anus  to  collect  the  feces.     This  is  held 

in  place  by  straps.     (Fig.  8.) 

The   Eectum. — Th.e   important    conditions    from   a   surgical 

standpoint  occurring  in  or  about  the  rectum  are:  (1)  ischiorectal 


Fig.  7. — Colostomy  Before  Being 
Incised.  A,  glass  rod  passed  through 
mesentery  of  colon;  B,  exposed  loop  of 
colon." 


Fig,  8. — Colos- 
tomy Bag. 


62  TEXTBOOK  OF  SURGICAL  NURSING 

abscess,  (2)  fistula  in  ano,  (1^)  lioiiiorrlioids,  (4)  caneer  of 
rectum. 

Ischiorectal  Abscess. — An  abscess  alxxit  the  rectum  is  like 
an  abscess  in  any  other  part  of  the  body  except  that  it  niijiht 
communicate  with  the  rectum,  and  if  not  ti'eated  properly  a 
fistula  might  result.  Tliis  is  a  tract  connecting  tlie  skin  and 
rectum.  For  this  reason  it  is  always  better  to  incise  and  drain 
the  abscess  as  soon  as  possible,  packing  the  abscess  cavity  and 
permitting  it  to  granulate  from  the  bottom. 

Fistula  in  Ano. — This  may  be  the  result  of  a  poorly  treated 
ischiorectal  abscess.  It  is  important  in  treating  the  fistula 
that  the  tract  be  excised  in  its  entirety  by  careful  and  complete 
dissection. 

Ante-operative  Treatment. — A  cathartic  is  given  twenty- 
four  hours  before  operation,  usually  an  ounce  of  castor  oil. 
Four  hours  before  operation,  the  lower  bowels  should  be  thor- 
oughly washed  with  a  warm  soapsuds  enema.  At  least  three 
of  these  should  be  given.  If  the  third  return  is  not  clear,  more 
enemata  should  be  administered  until  the  rectum  is  absolutely 
cleansed.  This  rectal  treatment  should  not  be  administered 
just  prior  to  operation,  because  much  of  the  liquid  material  is 
apt  to  be  retained  and  the  surgeon  is  hampered  in  his  work  by 
the  escape  of  rectal  fluid.  Some  surgeons  inject  the  fistulous 
tract  with  a  solution  of  methylene  blue,  a  dye  which  colors  the 
tract  making  its  ramifications  evident.  This  may  be  done  before 
or  after  the  anesthesia  has  been  begun. 

Operation. — Until  the  patient  regains  consciousness,  the  legs 
should  be  tied  together.  In  operations  about  the  rectum,  reten- 
tion of  urine  is  apt  to  result  and  great  care  should  be  taken  lest 
the  bladder  become  distended.  The  diet  should  be  constipating 
and  to  further  constipate  the  patient  a  pill  containing  opium  is 
given  three  times  a  day.  The  bowels  should  be  moved  upon 
the  fourth  day,  and,  after  the  movement,  the  parts  washed 
with  soap  and  warm  water,  and  fresh  packing  introduced.  The 
packing  must  be  changed  each  time  the  bowels  move,  if  stained 
with  fecal  material.  The  dressing  of  these  cases  is  exceedingly 
important.  If  the  packing  of  the  cavity  is  left  to  the  nurse,  she 
should  very  conscientiously  see  that  it  is  firmly  and  securely  in- 


NURSING  OF  THE  ALIMENTARY  SYSTEM  63 

trodueed  into  the  depths  of  the  granulating  cavity.  The  proper 
healing  will  do  much  to  prevent  a  recurrence  of  the  fistula. 

Hemorrhoids. — Piles  are  simply  dilated  veins  about  the  rec- 
tum. They  are  divided  into  the  internal  variety  (those  situated 
above  the  internal  sphincter),  and  the  external  variety  (beneath 
the  external  sphincter).  Piles  may  be  a  source  of  annoyance 
by  their  protrusion,  their  bleeding,  or  the  veins  may  become 
inflamed  and  thrombosed. 

Ante-operative  Treatment. — The  treatment  does  not  differ 
from  that  of  an  ischiorectal  abscess. 

Operative  Treatment. — After  the  patient  is  anesthetized,  the 
sphincter  ani  is  dilated  manually  as  a  preliminary  step  to  the 
operation.  This  gives  a  better  exposure  of  the  interior  of  the 
rectum,  and  by  paralyzing  the  sphincter,  the  after  pain  is  less, 
since  the  muscle  about  the  rectum  cannot  contract. 

The  piles  are  removed  by  (1)  simple  excision,  (2)  clamp  and 
cautery,  or  (3)  by  ligating  the  pile-bearing  area.  After  the  op- 
eration has  been  performed,  some  surgeons  insert  a  rectal  tube 
around  which  has  been  wrapped  two  or  three  layers  of  vase- 
linated  iodoform  gauze.  The  advantages  of  this  are  twofold: 
it  prevents  hemorrhage  and  it  enables  the  accumulated  gas  to 
escape;  but  it  has  the  great  disadvantage  of  being  rather  pain- 
ful and  uncomfortable  for  the  patient. 

Post-operative  Treatment. — The  same  measures  are  taken  as 
for  an  ischiorectal  abscess,  except  that  on  the  fourth  day,  when 
the  cathartic  is  given,  immediately  before  the  patient  moves 
the  bowels,  six  ounces  of  warm  olive  oil  are  introduced  into  the 
rectum  through  a  tube.  This  softens  the  accumulated  feces  and 
lubricates  their  passage.  Following  the  movement  of  the  bow- 
els, the  patient  should  be  instructed  to  take  Sitz  baths,  night  and 
morning.  These  are  comforting  and  are  very  helpful  in  healing 
the  denuded  areas  about  the  rectum.  For  a  period  of  two  to 
three  weeks  after  operation,  the  patient  should  receive  nightly 
an  ounce  of  licorice  powder,  as  it  is  essential  that  the  bowels 
be  kept  soft  and  loose.  The  patient  should  be  put  on  an  anti- 
constipation  diet,  a  good  example  of  which  may  be  found  in 
Chapter  XII  on  diets. 

Complications. — The  great  danger  in  a  hemorrhoid  opera- 


64 


TEXTBOOK  OF  SURGICAL  NURSING 


tion  is  that  of  hemorrhage.  If  a  patient  begins  to  faint  and  to 
show  the  signs  of  hemorrhage,  even  though  no  blood  is  visible 
externally,  -which  miglit  happen  if  a  rectal  tube  is  not  inserted, 
the  attending  surgeon  should  be  immediately  summoned.  The 
patient  is  placed  under  anesthesia,  a  tube  "en  chemise"  is  intro- 
duced and  the  rectum  firmly  packed.  A  tube  "en  chemise"  is 
simply  a  rubber  tube  to  the  rectal  end  of  which  gauze  is  at- 
tached.    (Fig.  9.)     It  is  inserted  into  the  rectum  and  packing  is 

introduced  between  the  tube 
and  gauze,  thereby  exerting 
pressure  on  the  bleeding  area. 
Sometimes  the  bleeding  point 
itself  may  be  ligated. 

Cancer  of  Rectum. — As  in 
other  locations,  cancer  in  this 
region,  provided  it  has  not 
progressed  too  far,  demands 
excision.  The  rectum  may  be 
excised  by  way  of  several 
routes,  —  by  the  perineal 
route,  the  sacral,  by  the 
vagina,  through  the  abdomen, 
or  by  a  combination  of  these. 
As  a  rule  any  excision  of  the 
rectum  is  preceded  by  a  pre- 
liminary colostomy.  The 
technic  of  this  has  alreadj^  been  described  on  page  60. 

Excision  of  Rectum  by  Perineal  Route. — The  patient  is 
placed  in  the  lithotomy  position  (see  Fig.  72,  page  277),  the 
anus  is  sewed  up,  and  the  rectum  is  dissected  from  the  sur- 
rounding tissues  until  the  upper  limit  of  the  growth  is  reached, 
and  then  it  is  excised. 

Excision  of  Rectum  by  Sacral  Route. — The  patient  is  placed 
in  the  Kraske,  or  reversed  Trendelenburg  position  (see  Fig. 
70,  page  276),  and  as  a  preliminary,  the  coccyx  and  a  portion 
of  the  sacrum  are  removed.  This  affords  freer  access  to  the 
rectum,  and  the  rectum  is  dissected  freely  and  excised. 

Excision  of  Rectum  through  the  Vagina. — In  this  operation 


.6 
Fig.  9. — Tube  "En  Chemise. "  A, 
layer    of    gauze    attached    to    rubber 
tube  B. 


NURSING  OF  THE  ALIMENTARY  SYSTEM  65 

the  posterior  wall  of  the  vagina  is  used  as  a  means  of  attack 
in  delivering  the  rectum  and  excising  it. 

Excision  of  Rectum  by  Combined  Method. — This  oi)eration 
consists  of  opening  the  abdomen  and  doing  the  operation  as  far 
as  possible  from  above,  then  closing  the  lower  end  of  the  bowel 
temporarily  and  delivering  the  upper  end  of  the  bowel  into  the 
wound  to  serve  as  a  colostomy  opening.  The  lower  segment  is 
finally  excised  by  the  perineal  route,  or  by  one  of  its  modifica- 
tions. This  entire  operation  may  be  performed  at  once,  or  in  two 
stages:  a  preliminary  colostomy  being  done  first,  and  the  radi- 
cal portion  later. 

None  of  the  afore-mentioned  operations  call  for  any  special 
nursing.  They  are,  however,  attended  with  a  great  deal  of 
shock,  and  the  nurse  should  be  ever  ready  to  institute  those  pro- 
ceedings which  she  has  learned  to  overcome  this  condition. 

The  Liver  and  Bile  Ducts. — Certainly  the  most  frequent  af- 
fection of  the  liver,  and  that  one  which  most  concerns  the  nurse 
is  that  of  gallstones  (cholelithiasis).  In  this  condition,  the  gall 
bladder  or  any  of  the  bile  ducts  of  the  liver  may  be  the  seat 
of  stones.  It  is  true  that  these  stones  may  lie  in  the  gall  bladder 
and  never  cause  any  symptoms.  But  when  the  stone  leaves  the 
gall  bladder  and  becomes  impacted  or  caught  in  some  of  the 
ducts — for  example,  the  cystic  or  common  bile  duct — symptoms 
of  gall  bladder  colic  ensue.  If  the  stone  is  impacted  in  a  cystic 
duct,  the  gall  bladder  may  become  slightly  dilated  with  resulting 
pain  and  tenderness  in  that  region ;  if  the  stone  becomes  im- 
pacted in  the  common  duct,  inasmuch  as  the  flow  of  bile  is 
impeded  on  its  way  to  the  intestine,  there  is  jaundice  which  may 
be  very  marked.  As  a  result  of  the  jaundice,  and  no  passage 
of  bile  into  the  intestine,  the  stools  are  white,  clay  colored, 
and  foul-smelling ;  the  urine  is  dark-brownish  in  color ;  and  the 
skin  is  yellow,  due  to  the  deposition  of  the  bile  pigment  in  the 
skin  itself. 

Medical  Treatment. — During  an  attack  of  colic,  the  patient 
is  given  large  doses  of  morphine  and  placed  in  bed.  Over  the 
region  of  the  gall  bladder  it  is  advisable  to  place  hot  applica- 
tions, either  poultices  or  stupes.  Following  these  attacks  the 
patient  should  have  a  light  diet  with  the  minimum  amount  of 


66  TEXTBOOK  OF  SURGICAL  NURSING 

fat.  Intestinal  elimination  should  be  kept  free  by  using  salts, 
especially  sodium  phosphate.  There  is  a  popular  superstition 
that  consuming  olive  oil  aids  the  free  passage  of  gallstones. 
This  is  very  mucli  exaggerated  and  without  scientific  foundation. 

Operative  Treatment. — Operative  measures  are  employed 
when  there  have  been  repeated  attacks  of  colic,  when  the  stone 
has  become  impacted,  or  when  the  gall  bladder  is  acutely  in- 
flamed or  filled  with  pus. 

Ante-operative  Treatment. — The  ante-operative  treatment  is 
of  extreme  importance  in  jaundiced  cases  because  jaundice  is 
one  of  the  factors  which  prevents  or  delays  the  clotting  of 
blood.  Naturally,  pre-operative  measures  must  be  taken  to 
ensure  a  lowering  of  the  coagulation  time.  This  may  be  accom- 
plished (previously  mentioned  in  detail  in  Chapter  III)  by  the 
administration  of  calcium  lactate,  horse  serum,  or  transfusion. 

The  position  of  the  patient  on  the  operating  table  is  impor- 
tant because  the  gall  bladder  and  its  passages  lie  deep  within  the 
abdomen,  and  every  effort  must  be  made  to  make  them  as  acces- 
sible as  possible.  This  is  attained  by  placing  the  patient  on  the 
table  so  that  the  gall  bladder  bridge  may  be  elevated,  thus  forcing 
the  liver  forward ;  or  a  sandbag  may  be  placed  in  the  region  of 
the  eleventh  or  twelfth  ribs.  Both  methods  yield  good  results. 
(See  Fig.  65,  page  272.) 

Operations. — The  operations  which  may  be  performed  upon 
the  gall  bladder  and  its  ducts  are  cholecystotomy,  cholecystost- 
omy,  cholecystectomy,  choledochotomy,  and  cholecystenterostomy. 

Cholecystotomy. — This  is  an  operation  in  which  the  gall 
bladder  is  opened,  the  stones  removed,  and  the  original  incision 
in  the  gall  bladder  closed.  It  is  not  often  performed  because 
the  gall  bladder  generally  requires  drainage. 

Cholecystostomy. — In  this  operation  the  gall  bladder  is  not 
removed,  but  it  is  drained;  the  drainage  is  placed  into  the 
gall  bladder  itself  by  burying  the  tube  with  a  purse  string 
suture. 

Cholecystectomy. — This  procedure  is  the  most  frequent;  it 
involves  the  removal  of  the  gall  bladder  and  the  ligation  of  the 
cystic  duct  and  cystic  artery. 

Choledochotomy. — In   those   cases  in  which  the  stone   lies 


NUESING  OF  THE  ALIMENTARY  SYSTEM  67 

impacted  in  the  common  duct,  the  removal  of  the  stone  hy  inci- 
sion of  the  duct  is  spoken  of  as  choledochotomy.  This  operation 
entails  drainage  of  the  common  bile  duct. 

Cholecystenter ostomy. — Sometimes  the  obstruction  of  the 
common  duct  is  such  that  it  cannot  be  removed ;  for  example, 
stricture  of  the  duct,  either  benign  or  carcinomatous.  If  the 
patient  is  suffering  from  intense  jaundice,  an  attempt  is  made 
to  short-circuit  the  bile.  This  is  done  by  establishing  an 
anastomosis  between  the  gall  bladder  and  the  stomach  or  between 
the  gall  bladder  and  the  small  intestines.  This  operation  is 
spoken  of  as  cholegastrostomy  or  cholecystenterostomy. 

Post-operative  Treatment. — Operations  in  and  about  the  gall 
bladder  are  accompanied  by  a  great  deal  of  shock,  and  as  most 
operations  involving  the  upper  abdomen  are  attended  by  a 
large  percentage  of  pneumonias,  all  means  must  be  taken  to 
insure  perfect  care  of  the  patient,  to  prevent,  him  from  being 
chilled  or  caught  in  draughts. 

In  those  cases  in  which  the  gall  bladder  is  drained,  or  where 
a  cholecystotomy  is  performed,  the  end  of  the  drainage  tube 
should  be  inserted  into  a  bottle  so  that  the  bile  may  be  col- 
lected, its  character  observed,  and  the  amount  estimated.  Oc- 
casionally, bile  will  leak  along  the  side  of  the  drainage  tube, 
resulting  in  a  general  soaking  and  discoloration  of  the  dressing. 
If  this  discharge  is  very  marked,  the  superficial  layers  of  the 
dressing  may  be  removed  and  fresh  compresses  applied. 

It  is  important  that  all  urine  should  be  examined  closely  for 
the  presence  of  bile,  and  that  the  stools  be  sent  to  the  laboratory 
to  determine  whether  bile  is  present.  While  the  gall  bladder  is 
draining,  the  patient  must  be  placed  upon  a  diet  which  is  poor 
in  fat,  because  the  bile  salts  which  aid  in  the  saponification  of 
the  fats  are  missing. 

Surgical  Conditions  of  the  Liver. — The  diseases  which  com- 
monly involve  the  liver  from  a  surgical  standpoint  are  injuries 
to  the  liver,  abscesses  of  the  liver  and  cin-hosis  of  the  liver. 

Injuries  to  the  Liver. — The  liver  may  be  injured  by  direct 
or  indirect  violence  ;  it  may  be  torn,  with  an  ensuing  hemorrhage. 
This  must  be  treated  by  immediate  laparotomy,  packing  the 
tear  with  gauze,  or  by  suturing  the  tear  of  the  liver  with  mat- 


68  TEXTBOOK  OF  SURGICAL  NURSING 

tress  sutures,  employirig  a  round,  non-cutting  liver  needle.     The 
suture  material   is  usually  ehromie  eatgut. 

Abscess  of  Liver. — This  may  be  of  pyogenic  origin,  or  the 
direct  result  of  amebic  dysentery.  These  abscesses  may  be 
opened  and  drained  directly  through  the  abdomen,  or  if  the 
abscess  is  high,  an  operation  may  be  performed  through  the 
posterior  lateral  area  of  the  chest.  The  parietal  and  visceral 
pleura  are  sutured  together,  and  after  adhesions  have  taken 
place,  so  as  to  seal  off  the  pleural  cavity,  the  liver  is  drained 
through  this  area.  In  this  way  no  pus  flows  through  the  abdomi- 
nal or  peritoneal  cavity,  or  through  the  pleural  cavity.  This 
operation  is  done  in  two  stages:  the  first  being  a  partial  resec- 
tion of  the  rib,  with  the  suturing  of  the  parietal  and  visceral 
pleura ;  the  second  is  the  drainage  of  the  abscess  through  the 
area  of  the  adhesions. 

Cirrhosis  of  Liver. — As  this  condition  is  associated  with  a 
filling  of  the  peritoneal  cavity  with  fluid  (ascites),  and  as  it  is 
presumably  due  to  an  obstruction  of  the  portal  circulation,  an 
attempt  is  made  to  establish  a  collateral  circulation  by  the  Talma 
operation    ( omentopexy ) . 

Twenty-four  hours  prior  to  operation,  an  ordinary  paracente- 
sis abdominalis  is  done.  The  patient  is  then  operated  upon, 
and  a  portion  of  the  omentum  brought  through  the  anterior 
abdominal  walls  in  the  midline  and  sutured  to  the  subcutaneous 
tissues.  In  this  way  the  omental  veins  will  establish  collateral 
circulation  with  the  internal  mammary  vein,  thereby  lessening 
the  strain  of  the  portal  system. 

The  one  important  factor  in  post-operative  treatment  is  when 
a  patient  strains,  the  abdomen  should  be  firmly  held  so  as  to 
prevent  further  evisceration  of  the  abdominal  contents  along 
with  the  omentum. 

Surgical  Conditions  of  the  Pancreas. — The  operations  upon 
the  pancreas  are  very  few  in  number.  The  only  diseases  which 
need  demand  our  attention  are  pancreatitis,  either  in  chronic 
or  acute  forms,  and  cancer  of  the  head  of  the  pancreas.  In 
inflammatory  diseases  of  the  pancreas,  inasmuch  as  the  bile  is 
supposed  to  be  an  irritating  and  causative  factor,  its  flow  is 
short-circuited  by  draining  the  gall  bladder  (cholecystostomy). 


NUESING  OF  TI-IE  ALIMENTARY  SYSTEM  69 

In  the  meanwhile  the  pancreas,  free  from  the  irritating  effects 
of  bile,  will  gain  a  much  needed  rest,  and  the  iniiammatory 
process  may  subside. 

Carcinoma  of  the  head  of  the  pancreas  may  encroach  upon 
the  opening  of  the  bile  duct  in  the  second  portion  of  the  duo- 
denum causing  intense  jaundice.  Inasmuch  as  new  growths  of 
the  pancreas  cannot  be  excised  without  a  terrific  operative  mor- 
tality and  disastrous  after  results,  the  only  operation  done  to 
relieve  the  unfortunate  jaundice  victims  is  that  of  drainage  of 
the  gall  bladder.  The  nursing  procedures  employed  in  these 
cases  are  similar  to  those  used  in  operations  upon  the  gall 
bladder. 

Hernia. — A  hernia,  or  rupture,  may  be  defined  as  "the  pro- 
trusion of  an  organ  or  part  of  an  organ  or  other  structure 
through  the  wall  of  the  cavity  normally  containing  it."  The 
rupture  is  named  from  the  region  in  which  it  appears.  There 
are  many  locations  where,  because  of  certain  mechanical  weak- 
nesses, hernia  is  quite  common.  It  occurs  very  frequently  in 
the  inguinal  region. 

Inguinal  hernia  is  a  form  of  rupture  that  occupies  the  in- 
guinal canal  either  partly  or  entirely;  if  it  occurs  the  condition 
is  spoken  of  as  an  indirect  hernia.  A  hernia  making  its  appear- 
ance almost  directly  into  the  external  abdominal  ring  is  called 
a  direct  hernia. 

Under  ordinary  conditions,  the  contents  of  the  hernial  sac  will 
disappear  into  the  abdominal  cavity  when  the  individual  is  at 
rest,  to  reappear  when  the  intra-abdominal  pressure  is  in- 
creased, as  during  coughing  or  arduous  physical  labors.  A 
hernia  which  disappears  is  known  as  reducible ;  if  because  of 
adhesions  this  does  not  occur  it  is  irreducible.  There  are  several 
varieties  of  the  irreducible  group :  Incarcerated, — a  type  of 
obstructed  hernia  containing  bowel  in  which  the  passage  of  fecal 
material  is  arrested  but  the  circulation  of  the  intestine  is  unim- 
paired. Strangulated, — a  hernia  in  which  not  only  the  bowel 
is  obstructed  but  also  the  blood  supply.  If  this  condition  is 
not  operated  upon  very  soon  after  its  incipiency  a  gangrene  of 
the  obstructed  loops  of  intestine  will  result. 

Other  varieties  of  hernia  are  femoral,  which  is  a  rupture  in 


70  TEXTBOOK  OF  SURGICAL  NURSING 

the  region  of  Seai"pe's  triangle  occurring  through  the  femoral 
ring;  umbilical,  which,  is  a  protrusion  through  the  abdominal 
wall  in  the  region  of  the  umbilicus.  Then  there  are  hernias 
which  occur  following  operation,  especially  in  those  cases  in 
wliit'li  tlie  abdominal  wall  has  become  weakened.  These  are 
known  as  post-operative  hernias. 

Occasionally,  especially  in  children,  the  hernial  sac  may  con- 
tain the  testicle ;  this  is  known  as  a  congenital  hernia  and  always 
accompanies  an  undescended  testis.  In  this  condition  the  tes- 
ticle is  not  in  the  scrotum  but  within  the  abdomen  or  inguinal 
canal. 

Treatment. — Hernia  may  be  treated  conservatively  with  a 
suitable  apparatus  or  truss  (an  appliance  made  to  exert  pres- 
sure over  the  hernial  opening  so  as  to  keep  the  contents  of  the 
sac  reduced)  but  since  the  public  are  becoming  educated  to  the 
wonderful  results  obtained  by  surgeiy,  it  is  most  always  treated 
radically  by  operation.  There  are  two  important  principles 
underl3'ing  all  hernia  operations :  the  obliteration  of  the  hernial 
sac,  and  the  closure  of  the  channel  along  which  the  hernia  pro- 
trudes. 

Ante-operative  Treatment. — The  same  ante-operative  rou- 
tine is  employed  as  for  all  chronic  cases  (Chapter  XIII).  The 
lower  abdomen  and  genitals  are  shaved  and  a  sterile  dressing 
is  applied.  Care  must  be  taken  that  the  external  genitalia  are 
not  painted  with  iodine.  In  the  operating  room',  the  operative 
field  is  repainted  with  iodine,  and  the  penis  and  scrotum  are 
enclosed  in  a  sterile,  wet  bichloride  towel. 

Operation. — An  incision  is  made  over  the  external  ring  up- 
ward along  Poupart's  ligament.  The  external  ring  is  identified, 
and  the  surgeon  calls  for  a  grooved  director  on  which  he  cuts  the 
fascia  of  the  external  oblique.  The  sac  is  then  identified,  dis- 
sected free,  its  base  transfixed  and  ligated  with  catgut  on  a 
curved  needle.  The  repair  of  the  hernia,  "the  closure  of  the 
channel"  is  then  performed,  the  suturing  being  done  with 
chromic  catgut,  kangaroo  tendon,  etc.  A  spica  bandage  (Fig. 
143)  in  addition  to  adhesive  plaster  keeps  the  dressing  in  place. 
A  plaster  spiea  is  often  used  in  children  where  immobilization  is 
absolutely  essential.    If  the  child  is  very  young,  the  spica  may 


NURSING  OF  THE  ALIMENTARY  SYSTEM  71 

be  coated  with  shellac  so  as  to  render  it  impervious  to  urine 
and  feces. 

Post-operative  Treatment. — As  soon  as  the  patient  reaches 
the  ward,  a  pillow  is  placed  under  the  knees,  and  as  soon  as  he 
is  conscious,  a  Bellevue  bridge  is  applied  across  the  thighs  to 
support  the  scrotum. 

The  cathartic  is  given  on  the  second  day  and,  as  a  rule,  pa- 
tients are  kept  in  bed  for  two  or  more  weeks.  For  the  first 
twenty-four  hours  catheterization  may  be  necessary. 

In  cases  of  incarcerated  and  strangulated  hernias  after 
the  sac  has  been  opened,  the  surgeon  will  cover  the  bowels 
with  moist  warm  saline  towels  for  about  ten  minutes,  and  if 
there  is  no  evidence  of  real  damage,  and  their  color  is  good, 
the  intestines  are  reduced  into  the  peritoneal  cavity.  If  the 
intestines  are  gangrenous,  an  intestinal  resection  will  have  to 
be  done.  These  cases  are  then  treated  like  any  other  case  of 
intestinal  resection. 

In  all  cases  of  hernia  it  is  very  important  to  impress  upon 
the  mind  of  the  recently  operated  that  for  a  few  months,  at 
least,  all  physical  exercise  should  be  of  the  mildest  kind,  and 
that  any  sudden  strain  must  be  avoided. 


CHAPTER  V 

THE  SURGERY  AND  SURGICAL  NURSING  OF  THE  GLANDULAR 

SYSTEM 

In  no  other  sj'stem  -witliin  recent  years  has  the  advance  been 
greater  and  the  research  more  extensive  than  in  the  field  of  the 
glands  of  internal  secretion.  It  is  true  that  we  still  know  very 
little  concerning  most  of  them.  But  possibly  Mdthin  the  next 
decade  or  so  there  will  be  great  light  shed  upon  the  physiology 
of  those  organs  which  either  alone  or  in  combination  control 
our  physical  and  mental  make-up.  Glandular  tissue  has  been 
described  as  that  tissue  which  has  for  its  function  the  secre- 
tion of  certain  substances.  These  may  be  of  service  to  the  body, 
as  the  digestive  juices,  or  they  may  be  purely  excremental  in 
nature,  removing  substances  which  are  either  poisonous  or  waste 
in  character. 

Classification  of  Glands. — It  is  convenient  to  divide  glands 
into  three  groups:  (1)  those  with  ducts,  (2)  those  without  ducts 
(the  glands  of  internal  secretion),  and  (3)  those  which  are  a 
combination  of  (1)  and  (2).  As  examples  of  glands  with  a  duct 
there  may  be  mentioned  the  liver,  the  largest  gland  in  the  body, 
which  secretes  and  excretes  bile  through  the  biliary  duet;  the 
submaxillary  glands,  the  mammary  glands,  the  prostate, 
sebaceous,  sudoriferous,  etc.  Pure  glands  of  internal  secretion 
may  be  represented  by  the  pineal,  the  pituitary,  the  thyroid,  the 
parathyroid,  and  adrenal.  Those  glands  which  are  both  exter- 
nal and  internal  in  secretion  are  represented  by  the  pancreas,  the 
ovary  and  the  testis. 

While  the  surgery  of  these  glands  is  limited,  probably  those 
deserving  most  of  our  attention  are  the  liver  and  the  bile  ducts 
which  have  been  discussed  under  the  gastrointestinal  tract. 
Chapter  IV,  the  ovary  and  testis  which  are  reviewed  in  Chap- 

72 


NURSING  OP  THE  GLANDULAR  SYSTEM  73 

ter  VIII  on  the  reproductive  system,  leaving  for  discussion  here, 
the  pituitary  and  the  thyroid. 

Diseases  of  the  Pituitary  Gland. — The  pituitary  gland  is 
composed  of  an  anterior  and  posterior  lobe.  It  arises  from  the 
forebrain  and  rests  in  the  sella  turcica  of  the  sphenoid  bone. 
The  function  of  the  pituitary  gland  is  probably  concerned  with 
growth.  Too  much  secretion  or  hyperpituitarism  is  a  condition, 
which,  if  it  occurs  before  the  ossification  of  the  epiphyses,  leads 
to  gigantism,  and,  when  it  occurs  latei*,  after  the  bones  have 
become  full  grown,  is  responsible  for  acromegaly.  Too  little 
secretion  of  the  pituitary  body  (hypopituitarism)  in  a  growing 
child  leads  to  increased  fat  deposition  in  the  tissues,  dwarfism, 
and  poor  development  of  the  sexual  organs.  "When  this  occurs 
in  the  adult  it  leads  to  adiposity  and  sexual  retrogression. 

Probably  the  eases  which  interest  us  most  from  the  surgical 
standpoint  are  those  in  which  the  pituitary  gland  is  enlarged, 
with  the  result  that  the  patient  complains  of  bitter  headaches, 
and  a  beginning  blindness.  This  is  often  seen  in  the  late  stages 
of  acromegaly,  a  condition  in  which  there  is  a  progressive  in- 
crease in  the  size  of  the  hands,  feet,  head,  jaw,  and  the  tissues 
about  the  face. 

Treatment. — Surgery  endeavors  to  remove  part  of  the 
pituitary  gland.  This  may  be  done  either  by  removing  part  of 
the  body  of  the  sphenoid  bone  via  the  nasal  route,  or  by  the 
subtemporal  path.     There  is  no  special  nursing  entailed. 

Diseases  of  the  Thyroid  Gland. — The  word  goitre  is  familiar 
to  the  lay  mind,  and  even  a  layman  distinguishes  two  types, — 
the  one  in  which  there  is  simply  an  enlargement  of  the  thyroid 
gland,  and  the  other  in  which  there  is  enlargement  complicated 
by  definite  nervous  symptoms.  Just  as  in  the  pituitary,  there 
may  be  an  increase  or  perversion  of  the  thyroid  secretion  kno'\\ai 
as  hyperthyroidism,  or  there  may  be  also  a  diminished  secretion. 
If  it  occurs  before  the  age  of  puberty,  or  dates  from  birth, 
cretinism  results,  or  if  it  occurs  in  adult  life,  myxedema  may 
occur. 

Cretinism. — These  children  have  a  diminished  thyroid  se- 
cretion. As  a  rule  they  are  fat  and  pudgy  with  coarse,  sparse 
hair,  unable  to  walk,  and  have  a  subnormal  temperature ;  their 


74  TEXTBOOK  OF  SURGICAL  NURSING 

mentality  is  practically  nil.  Thyroid  extract  given  to  these 
unfortunates  often  transforms  them  at  least  from  an  animal 
stage  to  a  point  where  they  can  protect  themselves  sufficiently 
to  exist. 

Myxedema. — Very  often  patients  in  adult  life  begin  to 
show  signs  of  mental  sluggishness  with  a  slow  reaction  time, 
and  their  faces  become  coarse  and  mask-like.  In  other  words, 
they  are  somewhat  like  a  cretin.  Thyroid  extract  or  any  prep- 
aration of  the  thyroid  gland,  given  by  mouth,  helps  these  people 
markedly. 

Goitre. — Any  enlargement  of  the  thyroid  gland  that  is 
chronic  in  nature  is  spoken  of  as  a  goitre.  There  are  certain 
regions  of  the  earth  where  this  disease  is  common ;  it  is  fre- 
quently seen  in  some  mountainous  places  of  Germany,  Austria, 
France,  Central  Asia,  Switzerland,  and  around  the  Great  Lakes 
in  Michigan.  It  is  thought  to  be  due  to  some  peculiar  agent 
found  in  the  drinking  water  of  these  districts.  The  symptoms 
which  come  from  the  goitre  are  mechanical,  and  result  from 
pressure  of  the  enlarged  gland  upon  those  structures  which  it 
might  compress.  From  pressing  on  the  wind  pipe  (trachea) 
it  may  give  rise  to  a  cough,  or  it  may  cause  difficulty  in  swallow- 
ing, by  pressure  on  the  gullet  (esophagus). 

Treatment  of  Goitre. — Goitre  may  be  treated  medically  or 
surgically.  Some  cases  respond  to  the  internal  administration 
of  potassium  iodide.  X-ray,  when  given  in  graduated  doses, 
sometimes  reduces  the  size  of  the  gland.  But  if  the  goitre  is 
large  and  the  symptoms  are  aggravating  and  persistent,  surgery 
is  practically  the  only  measure  which  will  afford  relief. 

Ante-operative  Treatment. — On  the  morning  of  operation 
the  neck  should  be  shaven,  cleansed  with  green  soap  and  water, 
followed  by  alcohol  and  ether,  and  a  sterile  dressing  applied. 

Operation. — Gas  and  oxygen  is  the  anesthetic  of  choice. 
The  patient  is  placed  upon  the  back  with  a  sandbag  beneath 
the  shoulders  so  as  to  put  the  neck  upon  a  slight  stretch.  (See 
Fig.  85,  page  289).  In  addition  to  the  ordinary  "set-up"  of 
instruments,  in  all  operations  upon  the  thyroid,  it  is  essential 
to  have  a  tracheotomy  outfit  in  readiness.  For  very  often  in 
these  operations,  due  to  pressure  upon  the  trachea,  it  collapses, 


NURSING  OF  THE  GLANDULAR  SYSTEM  75 

and  unless  instant  measures  are  instituted  to  relieve  the  strangu- 
lation due  to  the  closure  of  the  trachea,  death  will  readily  ensue 
because  of  asphyxiation.  This  horrible  complication  fortu- 
nately is  rare,  but  adequate  preparation  must  always  be  made 
to  meet  any  emergency.  Inasmuch  as  a  few  seconds  will  mean 
the  life  or  the  death  of  a  patient,  everything  should  always  be  in 
readiness  for  even  this  rarest  of  operative  complications. 

As  there  is  bound  to  be  a  moderate  amount  of  bleeding  and 
oozing  from  the  tissues,  a  small  cigarette  drain  is  employed  for 
about  24  hours,  and  the  ordinary  sterile  dressing  is  applied. 
Since  the  line  of  incision  in  a  goitre  operation  is  quite  visible 
in  the  modern  female,  attempts  are  made  to  minimize  the  scar 
as  much  as  possible.  To  ensure  perfect  healing  after  operation 
the  neck  is  usually  immobilized  by  means  of  starch  bandages; 
these  form  a  very  light  and  efficient  means  of  restraining  the 
grosser  motions  of  the  neck. 

Post-operative  Care. — The  patient  should  not  be  permitted 
to  talk  any  more  than  is  necessary  for  at  least  a  week.  Atten- 
tion should  be  paid  to  the  character  and  tone  of  the  voice.  The 
reason  for  this  is  obvious,  when  it  is  recalled  that  the  nerves 
which  partially  control  the  vocal  chords  lie  close  to  the  gland 
and  may  have  been  injured  or  cut  during  the  operation.  'This 
is  indeed  a  serious  complication,  because  if  they  are  cut  it  will 
result  in  permanent  alteration  of  the  patient's  voice. 

It  should  also  be  remembered  that  occasionally  patients  run 
a  high  temperature,  rapid  pulse,  and  may  even  be  delirious. 
The  syndrome  is  often  spoken  of  as  acute  thyroidism.  This  con- 
dition should  be  treated  with  ice  packs,  but  this  will  be  dis- 
cussed at  greater  length  in  the  treatment  of  exophthalmic  goitre. 

Exophthalmic  Goitre. — As  a  splendid  example  of  what  at- 
tention to  all  details  in  an  operation  will  do,  nothing  is  more 
striking  than  the  reduction  in  the  mortality  of  exophthalmic 
goitre  from  sixteen  per  cent,  to  practically  one  per  cent.  This 
has  been  made  possible  by  the  energetic  researches  of  Dr. 
George  Crile.  The  factors  which  have  caused  this  tremendous 
drop  have  been  the  use  of  gas  and  oxygen  as  an  anesthetic, 
local  anesthesia,  multiple  stage  operation,  coping  with  the  men- 


76  TEXTBOOK  OF  SURGICAL  NURSING 

tal   attitude,   bringing  the   operation   to   the   patient,    and   the 
employment  of  the  ice  pack  in  eases  of  acute  thyroidism. 

Symptoms. — Patients  with  exophthalmic  goitre  as  a  rule  are 
recognized  immediately  by  the  fact  that  their  eyes  are  promi- 
nent and  jirotrude,  and  that  they  are  extremely  nervous.  Their 
pulse  rates  vary  from  90  to  120,  and  sometimes  even  higher. 
In  other  words,  they  have  what  is  called  tachycardia.  Their 
skin  as  a  rule  is  moist,  and  tliey  perspire  freely.  A  very  definite 
swelling  of  the  thyroid  gland  is  often  visible.  These  symptoms 
all  point  to  a  poisoning  from  either  an  increased  amount,  or  a 
perversion  of  the  thyroid  secretion.  It  does  not  take  much 
imagination  to  realize  that,  above  all  else,  these  patients  need 
peace  and  quiet.  They  are  nervous  to  the  extreme.  Association 
■with  others,  incessant  talking,  and  noises  tend  greatly  to  aggra- 
vate them  and  increase  their  pulse  rate.  The  keynote  in  the  care 
of  these  patients  is  rest  under  ideal  surroundings  and  treatment 
administered  so  tactfully  and  carefully  that  the  shock  to  the 
nervous  system  will  be  of  the  minimum. 

Treatment. — Medical. — All  cases  of  exophthalmic  goitre 
should,  as  a  rule,  be  treated  medically  at  first.  The  treatment 
consists  of  rest  in  bed,  complete  isolation  from  society,  a  diet 
of  high  caloric  A-alue  with  forced  feeding,  and  the  administra- 
tion of  sodium  bromide  to  relieve  the  intense  nervous  excitement. 
Some  physicians  give  iodine  internally,  and  some  use  thyroid 
extract.  Detailed  accounts  of  the  medical  nursing  in  these  cases 
may  be  found  elsewhere. 

Surgical. — It  is  in  the  surgical  treatment  of  hyperthyroid- 
ism that  tremendous  strides  have  been  made.  The  patient  at 
present  is  not  operated  upon  the  day  after  she  enters  the  hos- 
pital.  These  highly  nervous  women  are  no  longer  subjected 
to  the  terror  of  being  ridden  directly  to  the  operating  room  and 
arriving  there  with  a  pulse  of  140 ;  then,  in  their  weakened 
condition,  subjected  to  ether  anesthesia  and  a  shocking  operation, 
with  the  result  that  having  little  stamina  left,  they  usually 
succumb  within  twenty-four  hours  after  a  partial  thyroidectomy 
has  been  attempted. 

Ante-operative  Treatment. — In  the  treatment  of  these  cases 
it  cannot  be  emphasized  too  strongly  that  great  tact  and  care 


NURSING  OF  THE  GLANDULAR  SYSTEM  77 

should  be  utilized  by  the  nurse  in  charge  so  as  to  gain  the  abso- 
lute confidence  of  the  patient.  The  room  which  the  patient  is 
to  occupy  should  be  bright,  well  ventilated  and  airy,  away  from 
all  noise  such  as  street  cars,  and  busy  corridors.  The  patient 
should  be  kept  continually  in  bed,  not  even  being  allowed  lava- 
tory privileges.  The  diet  should  be  plentiful,  an  accurate  ac- 
count kept  of  the  food  ingested,  and  the  caloric  value  figured 
accurately,  because  it  is  imperative  that  these  cases  be  given 
5,000  calories  or  more  of  food  a  day.  The  patient  should  be 
kept  quiet  on  liberal  dosage  of  bromides,  even  to  the  point  of 
bromidism.  Visitors  should  be  few,  and  their  period  of  stay 
limited.  All  depressing  topics  of  conversation  must  be  omitted. 
Anything  which  would  arouse  the  excitement  of  the  patient, 
such  as  dazzling  headlines  in  the  current  newspapers,  melodra- 
matic stories,  and  trashy  magazines,  must  not  be  permitted. 
Since  the  slamming  of  windows  and  doors  always  causes  a  sudden 
shock  to  the  patient,  great  care  should  be  taken  to  see  that  it  is 
not  done.  In  other  words,  the  medium  in  which  the  patient 
lives  must  be  calm,  serene  ana  peaceful. 

As  soon  as  the  patient  has  sufficiently  recuperated  from  the 
strangeiless  of  hospital  surroundings,  and  the  pulse  rate  has 
fallen  around  90,  it  is  advisable  to  acquaint  the  patient  with 
the  fact  that  she  is  to  prepare  for  operation.  The  anesthetist 
who  is  to  give  the  anesthesia  should  be  introduced ;  he  should 
explain  the  operation  of  the  gas  mask,  place  it  gently  over  the 
patient's  head,  teach  her  how  to  breathe  through  it,  aad  just 
what  she  is  expected  to  do.  He  should  visit  her  daily  and  re- 
hearse the  little  act  of  psychologically  anesthetizing  the  patient. 
In  the  meanwhile  the  nurse  should  prepare  the  neck  as  if  the 
operation  were  really  to  be  performed.  The  anesthetization  of 
the  patient  when  possible  should  be  done  in  her  private  room, 
and  as  the  patient  has  become  accustomed  to  the  anesthetist, 
the  mask  and  the  preparation  of  the  neck  by  the  nurse,  it  is 
possible  that  the  actual  day  of  operation  may  be  kept  secret 
from  the  patient.  In  other  words,  the  gland  may  be  stolen 
away,  the  patient  little  knowing  that  one  of  the  rehearsals 
with  the  anesthetist  is  the  day  on  which  the  operation  is  to  take 
place. 


78  TEXTBOOK  OF  SURGICAL  NURSING 

Tlu'  aiu'sllii'tic  wliicli  is  used  is  nitrous  oxide  and  oxygen,  and, 
in  addition,  tlu>  line  of  incision  is  iisnally  first  injeeted  with 
novocain,  !/:>%.  The  operation  is  usnally  done  in  stages;  that 
is,  the  blood  snpplj'  to  the  thyroid  is  first  lessened  by  the  ligation 
of  the  superior  thj-roid  arteries,  and  then  the  inferior  thyroid 
arteries.  This  may  be  done  under  local  anesthesia,  or  under 
gas  and  oxygen.  The  reason  for  the  preliminary  ligation  is 
to  diminish  the  blood  supply  of  the  thyroid.  This  simple  pro- 
cedure is  very  often  all  that  is  necessary,  and  with  it  the  symp- 
toms of  hyperthyroidism  abate  and  the  patient  needs  no  further 
surgical  treatment.  If,  on  the  other  hand,  the  symptoms  are  not 
definitely  improved,  at  least  the  blood  supply  of  the  gland  is  les- 
sened, so  that  when  the  thyroid  is  removed,  the  hemorrhage  will 
be  materially  decreased,  the  degree  of  shock  less,  and  a  speedy 
recovery  of  the  patient  assured. 

Post-operative  Treatment. — The  patient  should  be  kept  es- 
pecially quiet  and  given  plenty  of  fluid  by  rectum.  Very  often 
these  patients  are  subject  to  a  sudden  rise  in  temperature,  some- 
times as  high  as  106  degrees,  and  an  increase  in  pulse  rate  that 
is  rapid  and  thready.  Their  faces  become  pinched  and  covered 
with  perspiration;  they  are  apt  to  become  delirious  and  die 
within  a  very  short  time.  These  symptoms  are  thought  to  be 
due  to  an  acute  hyperthyroidism.  It  has  been  found  that  as 
soon  as  these  symptoms  occur,  they  can  be  controlled  by  the  use 
of  the  ice  pack. 

Occasionally,  following  the  operation  there  may  be  a  hemor- 
rhage from  the  operative  wound.  The  bandage  should  be  re- 
inforced and  the  operating  surgeon  immediately  summoned. 
More  rarely  a  condition  of  edema  of  the  glottis  may  develop. 
This  is  evidenced  by  difficulty  in  breathing,  cyanosis  of  the 
patient,  and  a  bubbling  respiration.  This  condition  demands 
immediate  attention,  often  tracheotomy  (Chapter  IX,  page  122), 
and  no  time  should  be  lost  in  summoning  the  medical  officer 
in  charge. 

Following  any  operation  upon  the  thyroid,  especially  of 
exophthalmic  variety,  the  patient  should  be  given  a  prolonged 
rest  in  some  quiet  mountainous  resort.  The  surroundings 
should  be  congenial,  and  the  patient  should  not  be  permitted 


NURSING  OF  THE  GLANDULAR  SYSTEM  79 

to  return  to  her  usual  environment  until  the  attending  physician 
feels  assured  that  she  can  stand  the  strain. 

Tetany. — Occasionally  after  rather  an  extensive  removal  of 
the  thyroid  gland,  a  peculiar  condition  may  result,  namely  that 
of  tetany.  This  is  presumably  due  to  the  fact  that  the  parathy- 
roid glands  which  are  closely  attached  to  the  posterior  surface 
of  the  thyroid  have  been  partially  removed. 

The  symptoms  of  tetany  are  intermittent,  bilateral  spasms 
confined  to  the  extremities.  These  paroxysmal  attacks  may  be 
controlled  by  the  administration  of  calcium  lactate,  about  fif- 
teen grains  every  three  hours. 


CHAPTER  VI 

THE  SURGERY  AND  SURGICAi  NURSING  OF  THE  NERVOUS 

SYSTEM 

The  nervous  system  consists  of  the  cerebrospinal  and  the 
sympathetic  or  autonomic  systems.  The  cerebrospinal  division 
is  made  up  of  the  brain  with  the  twelve  pairs  of  cranial  nerves 
and  their  peripheral  modifications,  and  the  spinal  cord  with  its 
thirty-three  pairs  of  spinal  nerves  and  their  peripheral  modifi- 
cations. The  autonomic  division  comprises  the  sympathetic 
ganglia  and  their  ramifications. 

Fractures  of  the  Skull. — While  these  injuries  should  really 
be  included  in  the  chapter  on  the  Osseous  System,  they  are  so 
closely  related  to  cerebral  trauma  that  a  brief  discussion  here 
might  be  deemed  more  advisable.  Fractures  of  the  skull  may  be 
divided  into  those  of  the  vault  and  those  of  the  base.  Fractures 
of  the  A'ault  may  be  simply  fissures  in  the  bone,  or  the  bone  may 
actually  be  depressed  and  splintered  into  several  fragments. 
These  cases  are  often  accompanied  by  injuries  to  the  blood 
vessels  of  the  dura  or  pia  mater,  or  by  actual  laceration  of  the 
brain  substance.  If  it  is  a  simple  fracture,  the  treatment  is 
that  of  elevating  the  depressed  bone  with  forceps,  or  periosteal 
elevators,  and  should  some  of  the  fragments  be  splintered  very 
badly  they  may  be  removed  with  rongeurs  or  punch  forceps. 
Occasionally  it  may  be  necessary  to  trephine;  this  is  described 
on  page  82. 

Fractures  of  the  base  are  more  serious  because  of  the  great 
danger  of  injuring  the  important  brain  structures  in  this  loca- 
tion. As  a  rule,  there  is  bleeding  from  the  nose,  sometimes  the 
ears,  and  occasionally  the  pharynx.  The  treatment  consists  of 
absolute  rest  and  quiet.  The  head  should  be  slightl,y  elevated 
and  fixed  between  two  pillows.  If  there  is  bleeding  from  the  nose 
it  is  advisable  to  irrigate  the  nasal  fosste  with  warm  boric  solu- 
tion to  prevent  the  clot  from  becoming  foul  through  infection. 

80 


NURSING  OF  THE  NERVOUS  SYSTEM  81 

In  cases  with  bleeding  from  the  ear,  it  is  best  to  irrigate  the 
external  auditory  meatus  after  which  the  canal  should  be  packed 
with  sterile  cotton.  The  irrigations  should  be  given  about  three 
times  a  day.  Qf  course,  the  bowel  movements  should  be  free. 
If  the  patient  is  unconscious,  about  two  drops  of  croton  oil  are 
placed  upon  the  tongue  to  insure  a  thorough  cleansing  of  the 
alimentary  canal.  Retention  of  urine  is  treated  by  catheteri- 
zation. Some  surgeons  give  all  these  cases  urotropin  in  doses 
of  from  ten  to  twenty  grains,  three  times  a  day,  for  it  secretes 
an  antiseptic  into  the  cerebrospinal  fluid.  If  these  fractures 
are  accompanied  by  signs  of  brain  injury,  and  of  intracranial 
pressure  from  hemorrhage,  operative  interference  is  necessary, 
although  the  mortality  is  extremely  high. 

Brain  Injuries. — The  brain  is  enclosed  within  a  bony  case, 
the  skull,  and  a  severe  injury  inflicted  upon  the  head  may  not 
only  injure  the  scalp  and  fracture  .the  skull,  but  also  cause 
various  injuries  to  the  brain  within.  The  immediate  effect  of 
the  injury  or  concussion  may  be  unconsciousness  brought  on  by 
shock  of  the  nerve  centers  of  the  brain.  In  addition,  some  blood 
vessels  of  the  dura  or  pia  mater  may  be  torn  with  a  resultant 
intracranial  hemorrhage  causing  compression  of  the  brain.  This 
manifests  itself  by  unconsciousness,  irregular  respirations  of  the 
Cheyne-Stokes  type,  slow  pulse,  increasing  of  the  blood  pres- 
sure, and  what  is  called  a  "choked  disc''  (serous  inflammation  of 
the  optic  nerve).  This  may  be  seen  with  an  ophthalmoscope, 
an  instrument  through  which  the  interior  of  the  eye  is  inspected. 

As  these  patients  are  in  shock,  they  should  first  be  treated  for 
this  condition,  but  they  should  never  be  placed  in  the  shock 
position.  In  fact,  the  head  should  be  elevated  slightly.  The 
room  must  be  quiet  and  darkened,  and  all  visitors  forbidden. 
As  a  rule,  an  enema  is  given,  and  if  the  bladder  is  at  all  dis- 
tended, a  catheter  is  inserted,  and  the  urine  drawn  off.  Pa- 
tients, after  they  have  recovered  consciousness,  should  be  con- 
fined to  bed  for  at  least  a  week  and  watched  very  carefully, 
because  very  often  peculiar  mental  symptoms  may  follow  in  the 
wake  of  a  concussion,  and  it  is  not  safe  to  leave  such  cases  alone. 

Treatment  cf  Compression. — This  presupposes  a  hemorrhage, 
either    extradural    or    subdural.      The    extradural    hemorrhage 


82  TEXTBOOK  OF  SURGICAL  NURSING 

results  from  a  rupture  of  one  of  the  branches  of  the  middle 
meningeal  arteiy.  Subdural  hemorrhage  is  due  to  a  rupture 
of  one  of  the  vessels  of  the  pia  mater,  or  a  laceration  of  the 
brain  with  its  vessels. 

Ante-operative  Treatment. -The  head  is  shaved  completely 
and  iodinized.  If  the  patient  is  unconscious,  no  anesthetic  is 
required;  if  not,  a  little  chloroform  is  sufficient.  The  head  is 
supported  on  a  sandbag,  or  small  prop.     (See  Fig.  83.) 

Operation. — A  curved  incision  is  made  in  the  temporal  re- 
gion of  the  head,  the  temporal  muscle  turned  down,  and  an 
opening  made  into  the  skull  by  means  of  an  instrument  called 
a  trephine.  This,  by  virtue  of  its  circular  serrated  end,  cuts 
out  a  button  of  bone.  After  the  bone  has  been  removed,  the 
dura  beneath  is  exposed.  If  better  exposure  is  necessary,  it 
may  be  obtained  by  enlarging  this  opening,  by  clipping  away 
more  bone  with  the  bone-cutting  forceps,  or  if  the  surgeon  pre- 
fers to  keep  the  bone  intact,  he  may  make  two  more  trephine 
openings,  and  connect  them  with  cuts  made  by  a  Gigli  saw. 
This  will  remove  one  large  plate  of  bone  that  may  afterwards  be 
replaced.  The  clot  is  then  removed,  and  the  bleeding  vessels 
are  found  and  ligated,  or  special  Gushing  clips  (small  metal 
clips)  are  placed  upon  the  artery.  If  the  bleeding  is  subdural, 
the  dura  is  incised,  and  the  source  of  the  hemorrhage  sought 
and  controlled.  The  dura  is  then  closed  with  interrupted  su- 
tures. The  bone  which  had  been  kept  in  warm  sterile  saline 
is  replaced  into  the  skull,  as  a  rule,  and  the  wound  closed  with 
or  without  drainage.  A  good  tight  pressure  bandage  is  applied 
over  the  entire  head.     (Figs.  122  and  123.) 

After  Treatment. — Patients  should  be  kept  in  bed  for  about 
two  wrecks.  During  this  period  they  should  be  allowed  very  few 
visitors,  and  absolutely  no  excitement.  They  should  never  be 
left  alone.  If  unconscious,  catheterization  should  be  performed 
every  eight  hours,  and  the  bowels  moved  by  enema  once  a  day, 
unless  incontinence  is  present.  In  these  pitiable  cases  great 
care  must  be  taken  to  keep  the  patient  exceptionally  clean  and 
free  from  feces  and  urine.  Unconscious  patients  must  be  turned 
every  four  hours  so  as  to  prevent  pressure  necroses  or  bed 
sores,  which  are  always  a  bad  reflection  on  the  nursing  care, 


NURSING  OF  THE  NERVOUS  SYSTEM  83 

although  often  absolutely  unavoidable.  If  the  skin,  especially 
around  the  bony  prominences  such  as  the  sacrum,  the  heels,  and 
elbows  be  carefully  bathed  with  alcohol,  gently  massaged  and 
powdered  there  is  very  little  danger  of  this  necrosis  taking  place, 
particularly  if  these  regions  are  elevated  for  a  few  hours  each 
day  by  inflated  rubber  rings.  During  convalescence,  the  pa- 
tient's mind  should  not  be  subjected  to  any  mental  strain  what- 
soever, and  the  surroundings  should  be  very  quiet. 

Brain  Abscess. — Occasionally,  septic  complications,  or  in- 
tracranial suppuration  may  follow  compound  fractures  of  the 
skull,  cerebral  injuries,  infections  of  the  middle  ear,  and  disease 
of  the  mastoid  antrum.  The  diagnosis  is  sometimes  very  diffi- 
cult, and  the  treatment  is  dependent  upon  the  location  of  the 
focus.  As  for  abscesses  in  other  parts  of  the  body,  the  immediate 
indication  is  drainage.  In  the  brain  abscess  this  presupposes  a 
craniotomy  (already  outlined)  with  drainage  of  the  abscess 
cavity. 

If  the  abscess  is  due  to  a  suppurating  middle  ear,  the  treat- 
ment is  a  little  more  involved.  To  begin  with,  if  pus  is  present 
in  the  middle  ear,  it  must  be  freely  drained  by  incising  the  drum. 
This  is  often  done  under  gas,  and  the  tympanic  membrane  in- 
cised by  a  small,  spear-like  knife  (myringotome).  Some  surgeons 
are  not  in  favor  of  syringing  the  ear  in  the  beginning,  but  keep 
the  drainage  free  by  wiping  the  meatus  clean  with  cotton  several 
times  a  day.  Others  prefer  to  have  the  ear  syringed  almost 
immediately  with  warm  boric  acid  solution  at  least  three  times 
a  day. 

Mastoiditis  and  Sinus  Thrombosis. — If  the  pus  spreads  from 
the  middle  ear  it  frequently  causes  an  infection  of -the  mastoid 
cells  (mastoiditis)  ;  if  it  enters  the  region  of  the  lateral  sinus 
(really  a  vein  running  in  a  groove  of  the  temporal  bone)  a  sinus 
thrombosis  may  result.  These  conditions  are  treated  by  surgical 
intervention. 

Ante-operative  Treatment. — The  hair  in  the  region  of  the 
ear  should  be  shaved  for  a  considerable  extent,  and  if  the 
jugular  vein  is  to  be  ligated,  the  neck  should  always  be  ver^^ 
carefully  prepared. 

Operation. — The  operation  consists  in  laying  open  and  goug- 


84  TEXTIU^OK  OK  SURGICAL  NURSING 

iiig  out  the  luastoiel  t-t'lls,  aiul  if  sinus  thrombosis  is  present, 
an  exposure  of  the  lateral  sinus.  In  ease  the  sinus  is  involved 
before  it  is  incised,  the  vein  into  which  it  drains  (internal  jugu- 
lar) is  Uprated  in  the  neck.  The  reason  for  this  is  to  prevent  the 
spread  of  infection  down  the  jug'ular  vein  into  the  general  eir- 
euhilion.  After  the  vein  has  been  ligated,  the  sinus  is  incised, 
the  clot  removed  by  careful  flushings  with  warm  saline  solu- 
tion, and  the  sinus  packed. 

After  Treatment. — Patients  suffering  from  a  sinus  throm- 
bosis are  very  sick.  As  a  rule,  they  are  septic  and,  like  all  those 
cases,  require  plenty  of  fluid  and  sufficient  calories  to  supply 
the  energy  their  constitutions  demand  to  fight  the  bacteria  in 
the  blood.  Not  only  should  they  be  given  saline  freely  by  rec- 
tum, but  if  necessary,  also  glucose  infusions  of  from  five  to 
ten  per  cent,  in  strength.  If  patients  are  anemic,  transfusions 
of  blood  are  indicated,  and  should  be  given  frequently  until  the 
blood  cultures  are  negative,  or  the  red  blood  cells  and  hemo- 
globin have  increased  to  within  normal  limits.  The  wounds  are 
dressed  daily,  cleaned  carefully  and  packed  anew;  the  dressings 
are  held  in  place  by  bandages.     (Described  in  Fig.  133.) 

Tumors  of  the  Brain. — The  brain  may  be  the  seat  of  a  tumor 
either  benign  or  malignant  in  nature.  As  the  mass  within  the 
cranial  cavity  grows,  it  crowds  the  brain  and  produces  signs 
of  compression  with  its  resultant  symptoms.  In  addition,  there 
will  be  other  physical  signs  dependent  upon  the  area  of  the 
brain  that  is  infiltrated  by  the  new  tissue,  or  compressed  by  the 
tumor  mass.  If  the  motor  area  is  pressed  upon,  there  may  be 
paralysis;  if  the  speech  area  is  involved,  there  will  be  paralysis 
of  those  muscles  which  they  innervate  or  loss  of  function  of 
the  nerves  supplying  the  organs  of  special  sense,  as  the  eye, 
ear  and  nose. 

Treatment. — If  the  tumor  mass  is  localized,  an  operation  is 
done  similar  to  the  one  described  under  intracranial  hemorrhage. 
In  other  words,  an  exploratory  craniotomy  is  performed,  and 
the  trephine  opening  is  made  in  that  portion  of  the  skull  over- 
lying the  brain  tumor  area. 

Occasionally,  the  tumor  may  be  extirpated  in  toto,  but  if  it  is 
found  to  be  inoperable,  a  plate  of  bone  is  removed  in  the  tern- 


NURSING  OF  THE  NERVOUS  SYSTEM  85 

poral  region,  and  the  brain  permitted  to  herniate  against  the 
temporal  muscle.  This  operation  is  called  ' '  subtemporal  decom- 
pression." Sometimes  in  tumors  of  the  cerebellum,  part  of  the 
occipital  bone  is  removed,  or  an  occipital  decompression  is  done. 
This  procedure  temporarily  relieves  intracranial  pressure,  and 
with  it,  the  terrible  persistent  headaches  which  torture  these 
unfortunate  individuals  almost  to  distraction.  Patients  are  con- 
fined to  bed  for  three  to  four  weeks. 

Surgery  of  the  Spinal  Cord. — The  surgery  of  the  spinal  cord 
is  really  limited  to  one  operation  [Icmvinectomy) .  Its  object  is 
to  expose  the  spinal  cord  for  examination  in  those  eases  suffering 
from  cord  pressure  due  either  to  a  tumor  mass  or  bone  frag- 
ments of  some  vertebral  fracture.  The  patient  is  placed  in  po- 
sitions illustrated  in  Fig.  68  or  83.  The  procedure  consists 
in  an  incision  over  the  desired  vertebras,  retracting  the  muscles 
attached  to  the  vertebral  column,  exposing  the  laminae  and  spines 
of  the  vertebrae,  which  are  then  removed  with  rongeurs,  laminec- 
tomy forceps,  saws,  and  chisels,  exposing  the  dura  of  the  spinal 
cord.  This  is  then  carefully  incised  and  an  exploration  of  the 
cord  is  made.  The  dura  is  then  sutured  and  the  muscles  drawn 
over  it.  A  moulded  cast  is  applied  over  the  back  well  into  the 
trunk,  and  the  wound  permitted  to  heal. 

Surgery  of  the  Spinal  Nerves. — Neuritis  (inflammation  of 
the  nerves)  is  really  a  medical  condition,  but  the  wounds  of 
nerves  are  very  important  from  a  surgical  standpoint.  If  a 
motor  nerve  is  cut  or  pressed  upon  so  that  the  nerve  fibers  are 
destroyed,  the  muscle  structures  supplied  by  it  become  paralyzed, 
and  the  nerve  below  the  point  of  incision,  or  pressure,  atrophies, 
although  the  part  above,  that  which  is  connected  with  the  nerve 
cells,  lives  on.  This  is  important  because  if  the  continuity  of 
the  nerve  is  reestablished  by  suture,  the  nerve  will  regenerate 
by  growing  along  the  path  of  the  degenerated  segment.  The 
strictest  asepsis  must  be  maintained  in  all  these  operations.  If 
the  nerve  is  simply  pressed  u-pon  by  callus  of  a  healing  bone  all 
that  is  necessary  is  to  remove  the  pressure;  but  if  the  nerve 
has  been  recently  divided,  it  should  be  immediately  sutured 
end-to-end  with  a  very  fine  round  needle  with  chromic  catgut. 
After  this  is  done,  the  wound  is  closed,  and  the  limb  placed  in 


86  TEXTBOOK  OP  SURGICAL  NURSING 

that  position  in  which  the  tension  upon  the  recently  sutured 
nerve  will  be  minimum,  A  plaster  splint  is  applied,  and  at 
the  end  of  one  week  or  ten  days,  active  and  passive  motions 
are  begun  so  as  to  keep  up  the  nutrition  of  the  muscles.  Mas- 
sage and  electrical  stimulation  should  also  be  begun  aronud  this 
period. 

The  splint  may  be  rcuioved  in  about  six  weeks  to  two  months. 
It  should  not  be  forgotten  that  nerve  regeneration  is  a  very 
slow  and  tedious  process,  and  very  often  as  much  as  two  years 
will  elapse  before  the  complete,  or  even  partial  restoration  of 
function  will  ensue.  The  patient  should  be  encouraged  to  mas- 
sage the  muscles  involved  so  as  to  prevent  atrophy  and  he  sliould 
be  taught  how  the  faradic  and  galvanic  electrical  currents  are 
applied,  so  that  when  attendants  are  no  longer  around,  he  may 
give  himself  those  treatments  which  will  mean  a  functioning 
extremity  rather  than  a  paralyzed  one. 

If  the  operation  is  done  some  time  after  the  original  injury 
the  process  is  more  difficult  and  the  various  plastic  nerve  opera- 
tions will  have  to  be  performed.  The  after  care  is  the  same  as 
that  required  for  recent  cases. 


CHAPTER  VII 


THE  SURGERY  AND  SURGICAX,  NURSING  OF  THE  OSSEOUS 

SYSTEM 


FRACTURES 

A  FRACTURE  may  be  described  as  a  break  in  the  continuity  of 
a  bone.  While  this  condition  is  treated  in  the  main  by  the  sur- 
geon, it  affords  great  opportunity  for  the  nurse  to  exhibit  her 
skill  not  only  in  preparing  the  necessary  things  for  the  treatment 
of  the  fracture  itself,  but  even  more  by  conscientiously  attend- 
ing to  those  details  that  bring  comfort  to  the  patient.  A  fracture 
may  be  simple,  that  is,  only  involving  the  bone,  or  it  may  be 
compottnd,  in  whiqh  case  the  skin  and  deeper  tissues  as  well  as 
the  bone  have  been  injured.  Compound  fractures  are  serious 
and  dangerous  because  the  broken  skin  affords  excellent  oppor- 
tunity for-  the  various  pathogenic  organisms  to  enter  and  cause 
bone  infection.  For  the  present,  however,  our  attention  will  be 
confined  to  simple  fractures,  those  in  which  the  skin  is  not 
directly  injured,  although  it  may  be  swollen,  black  and  blue,  and 
very  tender  to  the  touch. 

Simple  Fractures. — It  is  obvious  that  as  soon  as  any  bone 
is  broken  there  is  ordinarily  some  deformity  about  the  site  of 
fracture. '  This  may  be  due  to  the  hemorrhage  of  the  torn  vessels 
of  the  periosteum,  or  the  deep  muscles ;  or  it  may  be  due  to  the 
fact  that  the  fragments  of  the  injured  bone  are  displaced.  In 
the  normal  bone,  a  balance  exists  between  the  muscles  which  are 
attached  to  it.  When  the  bone  is  broken,  this  equilibrium  is 
destroyed  and  the  muscles  attached  to  each  fragment  tend  to 
pull  it  in  their  own  direction,  thereby  causing  displacement. 
This  is  not  true,  however,  in  all  cases.  Very  often  one  fragment 
is  telescoped  or  driven  directly  into  the  other.  This  is  spoken 
of  as  an  impacted  fracture. 

The  aim  in  all  fractures  is  to  restore  the  bone  fragments  as 

87 


88  TEXTBOOK  OF  SURGICAL  NURSING 

near  to  their  anatomical  condition  as  possible,  and  after  this  has 
been  accomplished,  the  next  thing  to  do  is  to  keep  the  fragments 
in  their  reduced  position.  The  first  process  is  usually  spoken  of 
as  "reduction,"  and  the  second  process  as  "immobilization." 

Reduction  of  Fractures. — Fractures  are  reduced  as  a  rule 
under  general  anesthesia,  either  gas,  gas  and  oxygen,  or  ether. 
This  is  done  because  it  is  less  painful,  the  patient  is  easier  to 
control  and  the  muscles  are  completely  relaxed  instead  of  being 
in  a  condition  of  spasm.  Attempts  at  reductions  are  done  by  the 
surgeon  as  soon  as  possible  after  the  injur3^ 

There  are,  however,  certain  fractures  which  do  not  yield  to 
manual  reduction  because  of  the  following  reasons:  (1)  Too 
much  time  has  elapsed  between  the  time  of  fracture  and  the 
period  when  the  surgeon  was  called  upon  to  treat  it,  (2)  the 
muscular  pull  between  fragments  is  so  great  that  manual  reduc- 
tion is  impossible,  (3)  the  fragments  although  reduced  are  not 
able  to  be  retained  in  their  reduced  position,  (4)  because  of  the 
imposition  of  bone  fragments,  muscle  or  torn  periosteum,  the 
fragments  cannot  be  brouglit  into  apposition.  These  fractures 
are  treated  either  by  means  of  apparatuses  designed  for  the 
gradual  reduction  of  fractures,  or  by  open  operation. 

Immobilization  of  Fractures. — Immobilization  (the  means  of 
keeping  fractures  at  absolute  rest)  has  for  its  ultimate  aim  the 
healing  of  the  divided  bone  ends  by  the  growth  of  new  tissue  or 
"callus  formation."  There  are  many  methods  designed  to  hold 
fractures  in  apposition.  They  may  be  classified  as  follows: 
(1)  bandages,  (2)  strappings,  (3)  splints  (wood,  wire  and 
plaster),  (4)  extension  and  traction  appliances,  (5)  mechanical 
means  applied  through  open  operation. 

It  is  a  general  rule  in  all  fractures  that  the  limb  affected 
should  always  be  placed  in  a  position  to  favor  the  complete  relax- 
ation of  the  muscles  which  would  have  a  tendency  to  pull  the 
fragments  apart,  and,  since  the  longer  fragment  can  always  be 
more  easily  controlled,  it  should  be  made  to  follow  the  position 
attained  by  the  shorter  fragment. 

Bandages  and  Strappings. — ^While  bandages  are  employed 
more,  in  sprains  and  dislocations,  they  are  occasionally  used  in 
certain  fractures.      Fractures  of  the  jaw  are  very   often   con- 


NURSING  OF  THE  OSSEOUS  SYSTEM  89 

trolled  by  a  simple  four-tailed  bandage  (Pig.  145,  page  389)  ; 
a  fracture  of  the  clavicle  may  be  kept  in  position  by  a  Velpeau 
bandage  (Fig.  140,  page  385)  or  a  Syms  strapping.  Both  the 
four-tailed  and  the  Velpeau  bandages  are  described  in  the  chap- 
ter on  bandaging. 

Strapping. — Strapping  is  of  greatest  use  in  sprains  and  a 
few  selected  fractures.  A  sprain  may  be  said  to  be  '^an  injury 
to  a  joint  with  possible  rupture  of  some  of  the  ligaments  or 
tendons,  but  without  dislocation  or  fracture."  In  fact,  it  is 
often  very  difficult  to  differentiate  between  these  conditions 
without  the  use  of  the  X-ray  or  the  fluoroscope. 

Treatment  of  Sprains. — The  present  day  trend  in  the  treat- 
ment of  sprains  is  to  apply  some  agent  which  will  stop  further 
effusions  into  the  joint  cavity,  aid  in  the  absorption  of  blood 
which  has  already  been  poured  into  the  joint  at  the  time  of  the 
injury,  give  support  to  the  injured  part,  and  yet  permit  the 
patient  to  move  the  traumatized  joint.  One  of  the  most  effective 
ways  to  accomplish  this  is  by  the  application  of  adhesive  strap- 
pings. If  the  swelling  about  the  joint  is  very  severe,  it  is  often 
advisable  to  apply  ice  for  the  first  twelve  hours,  usually  in  the 
form  of  wet  applications.  This  will  do  much  to  reduce  the 
swelling.  The  joint  is  then  ready  for  strapping.  This  is  done 
by  the  surgeon.  The  adhesive  is  applied  in  such  a  manner  as 
to  insure  support,  relieve  the  strain  from  the  ruptured  ligament, 
and  yet  permit  free  movement  of  the  affected  joint.  The  patient 
is  then  advised  to  walk  about  and  to  use  the  joint  as  much  as 
possible. 

The  strapping  is  left  undisturbed  for  about  a  week  and  is 
renewed  if  necessary.  Very  often,  when  the  ligaments  have 
definitely  ruptured,  some  surgeons  will  put  the  limb  up  in  a 
moulded  splint.  Baking,  massage  and  passive  movements  are 
allowed  and  are  usually  supervised  by  a  nurse.  Six  weeks  or 
more  may  elapse  before  the  healing  of  the  injury  is  completed. 
Strapping  is  used  very  extensively  in  sprains  of  the  ankle, 
wrist  and  knee. 

Strapping  for  Fractures. — This  is  used  most  frequently  when 
one  or  more  ribs  are  broken.  It  forms  an  efficient  method  for 
immobilizing  the  chest,  at  the  same  time  permitting  the  frac- 


90  TEXTBOOK  OF  SURGICAL  NURSING 

tiired  ribs  to  heal.  It  should  bo  emphasized  that  the  adhesive 
plaster  dressing  should  never  be  directly  applied  over  the  area 
of  fracture.,  with  the  exception  of  fractured  ribs,  because,  with 
the  swelling  of  the  limb  and  the  pressure  of  the  adhesive,  an 
ulceration  of  the  skin  is  apt  to  ensue.  The  result  is  that  a  clean 
fracture  maj'  be  converted  into  a  compound  one.  Another  rule 
in  the  application  of  adhesive  dressings  is  that  the  part  over 
which  the  adhesive  is  to  be  applied  should  be  shaven  of  all  hair. 

Splints. — "A  splint  is  an  apparatus  for  preventing  move- 
ment of  a  joint,  or  between  the  ends  of  a  broken  bone."  Since 
materials  used  for  splints  must  of  necessity  be  hard,  firm  and 
unyielding  they  should  always  be  padded  well.  There  is  nothing 
more  distressing  than  to  see  a  patient  with  a  simple  fracture  of 
the  radius  just  above  the  wrist  in  which  the  splint  was  not  only 
insufficiently  padded  but  was  applied  too  tightly.  The  result 
is  a  forearm  which  has  become  blistered,  ulcerated  and  paralyzed 
from  the  pressure ;  the  function  of  the  wrist  being  irretrievably 
impaired,  the  stiff,  smooth  fingers  are  an  ignominious  monu- 
ment to  the  carelessness  of  the  surgeon  and  the  attending  nurse. 
Let  it  be  an  unfailing,  unalterable  rule  that  all  fractures  in 
splints  of  any  description  be  regularly  inspected  so  that  the 
swelling  of  the  part  never  becomes  so  great  as  to  impair  the 
circulation.  The  pulse  at  the  wrist  in  fractures  of  the  arm  and 
forearm,  and  the  pulse  at  the  dorsum  of  the  foot  in  fractures  of 
the  lower  extremity  should  always  be  palpable  after  a  splint  has 
been  applied.  This  is  simple  and  safe  assurance  that  the  blood 
flow  to  the  limb  is  not  seriously  impaired.  Very  often  a  patient 
will  complain  of  i)ain  in  an  area  other  than  that  of  the  fracture. 
The  splint  should  always  be  carefully  inspected  to  determine 
the  source  of  the  discomfort.  Occasionally  in  circular  casts,  it 
is  a  good  plan  to  cut  a  window  in  the  plaster  in  the  area  of  pain 
so  as  to  relieve  the  pressure  which  is  invariably  causing  the  dis- 
tress. By  doing  this,  the  incidence  of  ulcers  from  pressure  will 
be  reduced  to  the  minimum. 

Before  any  splint  is  applied  it  is  of  prime  importance  to 
cleanse  the  injured  part.  The  nurse,  always  being  mindful 
of  the  injury,  should   do   this  gently  and   carefully,   causing 


NURSING  OF  THE  OSSEOUS  SYSTEM  91 

as  little  pain  as  possible.     This  procedure  should  be  completed 
by  dusting  the  skin  of  the  broken  limb  with  talcum  powder. 

Splint  Materials. — Any  material  which  is  light  and  strong 
is  suitable  for  a  splint.  The  following  are  some  of  the  more 
widely  used  materials: 

Wood. — Wood  has  been  used  for  centuries  to  support  broken 
limbs.  Probably  the  best  splints  are  the  basswood.  Basswood 
splints  usually  come  in  sizes  of  18x4x1/4  inches.  When  they  are 
padded  carefully  with  cotton,  they  make  a  good  temporary 
splint,  and  because  of  the  lightness  of  the  wood,  they  can  be  cut 
to  any  desired  size.  The  one  great  disadvantage  is  that  it  is 
impossible  to  mould  them  accurately. 

Plaster  of  Paris. — This  is  perhaps  the  most  widely  used 
splinting  material  in  civilian  practice,  and,  beyond  doubt,  its 
widespread  application  is  justifiable.  It  is  easy  to  obtain, 
strong,  moderately  light,  and  when  soft  lends  itself  to  accurate 
and  easy  moulding.  Plaster  of  Paris  is  best  handled  in  the  form 
of  plaster  of  Paris  bandages.  The  manner  in  which  they  are 
made  is  given  in  Chapter  XX.  There  are  two  ways  in  which 
these  bandages  may  be  applied.  They  may  be  used  as  bandages 
or  '^ moulded  splints." 

Plaster  of  Paris  Bandages. — These  are  applied  as  any  other 
bandage,  the  limb  having  been  previously  padded  with  non- 
absorbent  cotton.  Extreme  care  should  be  taken  to  apply  the 
bandages  smoothly,  without  wrinkles  and  rather  snugly.  The 
number  used  is  dependent  upon  the  desired  thickness  of  the 
cast.  After  this  has  been  obtained,  the  cast  may  be  further 
smoothed  by  applying  an  excess  of  plaster  and  polishing  the  same 
with  long  strips  of  cheese  cloth  moistened  with  peroxide  of 
hydrogen.  Plaster  usually  dries  in  from  one  to  eight  hours. 
For  the  first  thirty  minutes,  the  limb  should  be  held  until  the 
plaster  has  partially  dried,  because  the  cast  may  become  dis- 
torted by  pressure  of  surrounding  objects. 

While  it  is  not  a  universal  practice,  a  great  many  surgeons 
deem  it  advisable  to  cut  all  circular  casts  in  the  direction  of  their 
longitudinal  axis,  in  two  parallel  lines,  diametrically  opposed. 
The  reason  for  this  is  obvious.  Should  the  limb  become  swollen, 
the  danger  of  any  untoward  complications,  such  as  pressure 


92  TEXTBOOK  OF  SURGICAL  NURSING 

necrosis,  with  a  subsequent  Volkmann's  paralysis,  is  materially 
lessened.  AVlieii  the  cast  has  been  cut,  a  bandage  is  applied  to 
hold  the  segments  in  place.  Not  only  does  cutting  down  a  cast 
insure  a  "safety  first"  policy,  but  it  becomes  very  convenient 
to  do  so  when  baking  and  massage  are  employed  as  the  cast 
may  be  quickly  removed  and  efficiently  reapplied  after  each 
treatment. 

If,  for  some  reason,  the  surgeon  sliould  decide  to  leave  the 
cast  intact,  and  to  have  it  cut  at  a  subsequent  date,  it  must  not 
be  forgotten  that  dried  plaster  is  almost  stone-like.  The  method 
of  cutting  casts  is  given  on  page  397. 

Moidded  Plaster  of  Paris  Splints. — As  the  name  implies, 
these  are  simply  splints  made  up  of  plaster  of  Paris  which,  when 
soft,  may  be  moulded.  They  are  very  extensively  used  because 
they  are  easily  applied,  safer  than  the  circular  cast,  and  save 
the  labor  of  cutting  through  plaster.  They  may  be  used  for  all 
fractures  of  the  extremities.  Assume  a  fracture  of  the  radius 
just  above  the  wrist,  a  so-called  Colles  fracture.  The  manner 
of  applying  a  moulded  splint  to  this  type  of  fracture  is  here- 
with briefly  given :  The  length  of  the  splint  to  be  used  is 
measured  with  a  piece  of  gauze,  in  this  case  from  the  elbow  to 
the  metacarpo-phalangeal  joint,  and,  in  addition,  the  width  of 
the  arm  is  noted.  This  pattern  of  the  splint  in  gauze  is  laid  flat 
upon  some  smooth  surface,  either  glass,  marble,  or  board.  A 
moistened  plaster  bandage  is  rolled  back  and  forth  over  the  gauze 
pattern,  until  the  desired  thickness  of  the  splint  has  been 
attained.  A  piece  of  canton  flannel  usually  lines  the  inner  side 
of  the  splint.  The  soft  plaster,  lined  with  flannel  and  a  thin 
layer  of  cotton,  is  applied  to  the  anterior  surface  of  the  fore- 
arm, and  bandaged  snugly  in  place.  The  anterior  splint  in  this 
way  can  readily  be  moulded  to  the  shape  of  the  arm.  After  the 
plaster  has  hardened  the  bandage  is  removed,  all  the  rough  edges 
of  the  splint  smoothed  and  a  muslin  bandage  reapplied.  Some 
surgeons  in  addition  to  an  anterior  splint  apply  a  posterior  one. 
The  technic  is  identical  for  all  of  the  moulded  variety.  Very 
often  a  splint  will  be  made  double  in  length  and  be  bent  upon 
itself  in  the  shape  of  a  letter  U,  forming  a  joint  anterior  and 
TDosterior  one.    This  type  is  known  as  a  "sugar-t9M"  splint.    It 


NURSING  OF  THE  OSSEOUS  SYSTEM  93 

finds  a  very  practical  application  in  fractures  of  hotli  bones  of 
the  forearm. 

Spicas  and  Jackets. — When  a  long  bone  is  broken,  such  as 
the  femur,  or  the  pelvis,  heavier  splints  are  required  because 
greater  strength  is  necessary  to  overcome  the  powerful  contract- 
ing influences  of  the  muscles  of  the  thigh.  Splints  in  this  region 
have  but  little  value  aside  from  their  first  aid  application.  If 
the  surgeon  desires  to  use  plaster  for  these  conditions  a  spica 
bandage  of  plaster  of  Paris  is  employed.  These  extend  from  the 
region  of  the  umbilicus  down  to  the  toes  on  the  affected  side. 

The  technic  of  the  application  of  the  plaster  is  the  same, 
but  there  are  several  factors  which  are  a  little  different  and 
demand  special  mention.  First  the  mechanical,  for  after  all, 
plaster  has  only  a  certain  tensile  strength.  If  this  is  exceeded, 
the  plaster  is  apt  to  crack  and  break,  rendering  the  spica  useless. 
In  order  to  prevent  this,  it  is  customary  to  reinforce  the  east, 
especially  in  the  lateral  region,  i.  e.,  from  the  hip  to  the  knee 
and  over  the  anterior  aspect  of  the  thigh.  The  reinforcing 
naaterial  may  be  strips  of  basswood,  wire  mesh,  or  sometimes 
longitudinal  strips  of  plaster  of  Paris  in  the  form  of  moulded 
splints.  ■  Then,  in  applying  the  cast,  inasmuch  as  the  lower 
abdominal  region  is  included,  sufficient  space  must  be  allowed 
for  the  possible  distention  of  the  small  and  large  intestines. 
In  other  words,  ample  room  must  be  left  for  the  patient's  appe- 
tite. This  is  accomplished  by  laying  two  or  three  folded  towels 
on  the  abdomen,  and  winding  the  plaster  so  as  to  include  them 
temporarily,  removing  them  after  the  plaster  has  hardened. 

Since  the  spica  winds  about  the  genitals  and  anal  orifice, 
great  care  must  be  taken  that  there  is  no  undue  pressure  against 
these  organs,  and  tliat  the  patient  is  able  to  defecate  and  urinate 
without  difficulty.  In  children  whose  control  is  apt  to  be  lax  or 
involuntary,  it  is  customary  to  coat  the  cast  with  shellac,  thus 
rendering  it  impervious  to  the  urine.  Spicas,  as  well  as  all  other 
complicated  plaster  work,  are  applied  with  great  facility  and 
more  efficiently  if  the  patient  is  resting  on  a  "Hawley"  table. 

The  Hawley  table,  or  modifications  of  it,  is  of  such  mechanical 
construction  that  any  part  of  the  bony  framework  of  the  patient 
may  be  held  in  any  desired  position  for  any  length  of  time  with- 


94  TEXTBOOK  OF  SURGICAL  NURSING 

out  the  aid  of  xeiy  much  assistance.  Tliis,  of  course,  is  a  wonder- 
ful advance  over  those  methods  Avhich  required  a  limb  to  be  held 
in  a  certain  position  by  a  nurse  or  doctor  until  the  plaster  could 
be  applied.  The  Ilawley  table  may  be  used  not  only  for  the 
application  of  casts,  spicas,  and  plaster  jackets,  but  it  is  a  con- 
venient means  to  steady  a  limb  and  obtain  traction  if  necessary, 
during  the  course  of  an  open  operation  upon  bone. 

Plaster  Jackets. — These  are  coats  or  jackets  made  of  plaster 
tliat  cover  the  patient  from  the  neck  well  to  the  region  of  the 
thighs.  It  finds  its  application  in  dislocations  of  fractures  of 
the  vertebra?  due  to  either  accidental  causes  or  to  disease,  such 
as  tuberculosis  of  the  spine.  It  may  be  applied  with  the  patient 
resting  either  on  the  Hawley  table,  or  with  the  patient  lying 
across  some  supporting  straps. 

Methods  to  Obtain  Traction. — In  some  cases,  the  fragments 
of  the  fracture  are  overriding  to  such  a  degree  that  were  the 
limb  permitted  to  heal  in  this  position  great  deformity  and 
shortening  of  the  leg  or  arm  would  result.  To  overcome  this, 
and  to  correct  the  overlapping  of  bones,  traction  may  be  applied. 
Nothing  has  developed  the  use  of  traction  more  than  the  Great 
"War.  For  there,  not  only  did  the  surgeon  have  to  deal  with 
fractured  limbs  but  with  fractured  limbs  plus  injuries  to  the  soft 
parts  (compound  fractures).  To  overcome  these  difficulties, 
which  are  practically  impossible  to  handle  if  the  limb  is  encased 
in  plaster,  an  attempt  is  made  to  maintain  reduction  by  traction 
often  combined  with  suspension. 

Traction. — Traction  is  used  to  correct  overlapping  or  over- 
riding bone  fragments  and  lateral  deformities.  Through  its 
agencj^,  those  muscles  are  relaxed  which  by  their  contraction 
might  have  resulted  in  malpositions  of  the  fracture.  In 
addition,  if  properly  applied,  it  automatically  secures  the 
proper  alignment  of  the  bone  ends  and  prevents  the  fragments 
from  being  displaced,  thus  avoiding  injuries  to  muscles,  blood 
vessels,  or  nen-es. 

In  civilian  practice,  traction  was  practiced  freciuently  for 
fractures  of  the  femur  either  through  a  Buck's  extension  or  a 
Hodgen's  splint.  Briefly,  the  Buck's  extension  is  made  by 
applying  to  the  lateral  aspects  of  the  leg  a  piece  of  adhesive 


NURSING  OF  THE  OSSEOUS  SYSTEM 


95 


plaster  about  four  inches  wide,  reaching  from  above  the  knee 
to  below  the  sole  (Fig.  10,  B).     Between  the  free  ends  of  the 


K 


Wood 


Fig.  10. — Methods  of  Applying  Traction.  A,  stocking  traction;  B, 
adhesive  plaster  traction;  C,  Sinclair  skate.  From  the  Manual  of  Splints 
and   Appliances,    Medical    Department,    United   States   Army. 


adhesive  a  piece  of  wood,  five  by  three  inches,  is  attached.  This 
acts  as  a  spreader,  and  a  means  by  which  weights  may  be 
attached  and  traction  obtained. 


96  TEXTBOOK  OF  SURGICAL  NURSING 


U  ^ 


Fig.  11\ — Traction  Leg  Splint.     A,  Thomas  traction  leg  splint  with  sus- 
pension. 

The  Hodgen's  suspension  splint  (Fig.  11"),  which  is  really 
a  forerunner  of  the  various  splints  developed  recently,  is  simply 
two  parallel  iron  bars  bent  slightly  in  the  region  of  tlip  knee. 
The  lower  extremity  is  placed  between  these  two  bars,  resting 
on  several  cross  pieces.  The  limb  is  raised  from  the  bed  by 
cords  attached  to  the  splint  and  traction  is  obtained.  Further 
traction  may  be  obtained  by  combining  this  with  a  Buck's 
extension. 

As  the  Buck's  extension  depends  for  its  traction  pull  upon 
large  areas  of  skin  being  covered  by  adhesive,  it  was  found 
impractical  during  the  war  because  extensive  wounds  of  the 
skin  and  deeper  tissues  often  complicated  the  fractures.  So 
newer  metliods  of  traction  Avere  developed, — namely,  the  stocking 
traction  (Fig.  10,  A)  and  the  Sinclair  skate  (Fig.  10,  C).  The 
former  emploA-s  a  light  Aveight  sock  from  which  the  toes  have 
been  removed.  The  sock  is  glued  to  the  leg,  ankle  and  foot  except 
at  its  sole,  and  a  piece  of  splint  wood  is  introduced  between  the 


NURSING  OF  THE  OSSEOUS  SYSTEM  97 

J31  ^  H  H _  ^ 


Fig.  11^ — Traction  Leg  Splint. 

B,  wooden  bed  frame. 

For  traction  by  weight  and  pulley  and  overhead  counterweight  sus- 
pension. 

Application  for  lower  limb  injuries. 

Limb  in  anterior  thigh  and  leg  splint,   Hodgen  type. 

Uses : — 

For  suspension  of  limb  from  overhead  support  in  injuries  of  thigh 
and  leg. 

A.  Supporting  slings  clipped  to  rods  of  splint. 

B.  Cloth  glued  to  sole  of  foot  attached  to  counterweight  arranged  to 

maintain  right-angle  dorsal  flexion. 

C.  Hand  grips  by  which  patient  may  change  his  position  in  bed. 

H.  Strap  iron  hooks  movable  on  upper  cross-bar  of  frame  but  screwed 
to  short  wood  bar  to  maintain  pulleys  in  proper  relative  position. 

W.    Open  canvas  weight  bags. 

This  splint  is  used  simply  for  a  frame  to  sling  the  leg  in  case  the  nature 
of  the  wounds  makes  the  Thomas  splint  impossible.  The  traction  straps 
should  be  attached  directly  to  the  weight  and  pulley,  and  should  not  be 
attached  to  the  splint. 

By  careful  adjustment  of  the  slings  the  position  of  the  bone  fragments 
can  be  controlled.  From  the  Manual  of  Splints  and  Appliances,  Medical 
Department,  United  States  Army. 

sock  and  the  sole  of  the  foot.  Traction  is  obtained  by  means 
of  a  cord  passed  through  the  sock  and  splint.  A  further  refine- 
ment is  the  Sinclair  skate;  this  is  a  piece  of  board  attached  to 
the  foot  by  adhesive  strips  or  glued  strips.  The  glue  that  is 
used  may  be  made  after  the  following  forniulte  and  directions 


98  TEXTBOOK  OF  SURGICAL  NUESING 

obtained  from  the  "Manual  of  Splints  and  Appliances"  (Med- 
ical Department,  United  States  Army). 

SINCLAIR'S  GLUE 

Glue  50  parts 

Water 50      " 

Glycerine     2      " 

Calcium  chloride 1  part 

Thymol    1      " 

The  glne  is  heated  in  a  water  bath  to  about  100°  F.  It  is 
painted  on  the  skin,  the  last  coat  given  is  painted  in  a  direction 
against  the  growth  of  hair. 

EESIN  AND  TURPENTINE  GLUE 

Resin    50  parts 

Alcohol     50      " 

Benzine    (pure)     ...  .50      " 
Turpentine    5      " 

To  the  powdered  resin,  one-half  the  alcohol  is  added,  then  the 
turpentine  and  benzine.  The  measure  is  washed  with  the 
remaining  alcohol  and  the  contents  poured  into  a  bottle.  The 
bottle  is  always  kept  tightly  corked.  The  glue  may  be  removed 
with  alcohol  or  ether.  No  heat  is  necessary  for  its  application 
and  it  should  be  applied  as  thinly  as  is  possible. 

Suspension. — ^While  traction  is  an  important  element,  sus- 
pension  has  enhanced  its  value  by  rendering  greater  comfort  to 
the  patient,  and  making  much  easier  the  surgical  dressing  of  the 
wounds.  The  limb  is  usually  suspended  to  an  overhead  wooden 
or  metal  frame  (Fig.  11-)  developed  from  the  original  Balkan 
frame.  This  consisted  of  two  uprights  with  a  cross  piece  at  each 
foot  of  the  bed  supporting  a  horizontal  bar.  The  frame  now  in 
use  is  a  quadrilateral  variety  and  is  illustrated  in  Fig.  11^. 

To  this  frame  may  be  attached  various  pulleys,  or  these  pulleys 
may  be  run  on  trolleys  as  shown  in  Fig.  12,  A,  and  Figs.  11^  and 
11  ^ 

There  are  several  splints  which  have  been  recently  developed, 
and  although  their  application  and  suspension  is  the  concern 
of  the  orthopedist  and  surgeon,  the  nurse  should  have  a  knowl- 
edge sufficiently  great  to  secure  the  desired  appliances  at  the 


NURSING  OF  THE  OSSEOUS  SYSTEM 


99 


^yn-^ 


Fig.  12. — Traction  Arm  Splints.  A,  Thomas  traction  arm  splint; 
B,  Thomas  arm  splint;  C,  Thomas  traction  arm  splint.  From  the  Manual 
of  Splints  and  Appliances,  Medical  Department,  United  States  Army. 


100  TEXTBOOK  OF  SURGICAL  NURSING 

splint  room,  and  in  tlio  event  of  anytliiiig  oeeurring  to  tlieni  in 
the  absence  of  the  attending  doctor,  she  may  apply  "first  aid." 
The  ones  most  eonnuonly  used  are  those  mentioned  in  the 
"Mannal  of  Splints  and  Appliances"  issued  by  the  Medical 
Department,  United  States  Army,  and  illustrated  herewith. 

Thomas  Traction  Arm  Splint. — Tliis  is  used  for  fractures  of 
the  shoulder  joint,  shaft  of  the  humerus,  elbow  joint,  and  fore- 
arm (Fig.  12). 

Jones  "Cock  Up"  or  "Crab"  Wrist  Splint.— This  is  intended 
for  injuries  to  the  wrist,  or  to  maintain  dorsal  flexion  of  the 
hand  in  injuries  to  the  wrist,  and  in  injuries  to  nerve  and  muscle 
causing  wrist  drop  (Fig.  13), 


Fig.  13. — Jones  ' '  Cock  Up,  "  or  "  Crab  ' '  Wrist  Splint.    From  the  Manual 
of  Splints  and  Appliances,  Medical  Department,  United  States  Army. 

Thomas  Traction  Leg  Splint. — This  is  for  injuries  to  the 
shaft  of  the  femur,  knee  joint,  and  leg  (Fig.  11^). 

Hodgen  Type  Splint. — This  is  for  injuries  to  the  thigh 
(Fig.  IP). 

Open  Operation  for  Fractures. — In  these  fractures,  which  are 
not  compound,  when  reduction  has  been  impossible,  it  is  often 
necessary  to  perform  an  open  operation,  reduce  the  fracture 
under  the  direct  vision  of  the  surgeon,  and  then  hold  the  frag- 
ments in  place  by  some  mechanical  measure.  The  means  of 
accomplishing  this  are  many.  Some  use  wire,  others.  Lane 
plates ;  the  latter  are  pieces  of  metal  which  bridge  bones  together, 
the  plate  being  held  fast  to  the  bones  by  screws  (Fig.  14). 

Occasionally,  although  the  bones  are  in  good  position,  union 
by  callus  formation  fails  to  take  place.  To  stimulate  bone 
growth  a  piece  of  bone  may  be  taken  from  some  other  part  of 
the  body,  as  a  graft  from  the  tibia,  and  this  is  inserted  into  the 
fractured    bone    ends.     Inasmuch    as    infection    is    very    much 


NURSING  OF  THE  OSSEOUS  SYSTEM  101 

dreaded  in  these  operations,  an  exaggerated  technic,  or  Lane's 
teehnic,  is  employed.  This  is  a  method  whereby  everything  that 
goes  into  or  comes  into  contact  with  the  wound  is  not  touched 
by  gloved  hands,  but  by  instruments.  The  technic  is  briefly  out- 
lined in  Chapter  XVII.  The  wound,  of  course,  is  closed  with- 
out drainage,  and  the  limb  put  up  in  some  splint  or  fixation 
apparatus. 

Osteomyelitis. — This  is  an  inflammation  of  the  medulla  or 
marrow  of  the  bone.  It  may  be  acute  or  chronic,  and  generally 
results  from  a  bacterial  infection.  All  those  compound  fractures 
of  the  war,  due  to  shrapnel  and  machine  gun  bullets,  were  com- 
plicated, as  a  rule,  by  osteomyelitis  in  varying  degrees. 

Symptoms. — The   symptoms  may  consist  of  great  pain  re- 
ferred to  the  bone  affected,  high  fever,  rapid 
pulse,  and  general  malaise.     There  may  be 
swelling,  redness,  and  marked  tenderness  ,^ 

on  pressure  over  the  involved  area. 

Treatment. — The  treatment  is  operative.      b 
An  attempt  is  made  to  give  the  bone  free 
drainage  by  incision  through  the  skin  and 
muscles  and  then  sufficient  cortex  of  the  bone      Plate!    A  fractured 

is  removed  to  permit  the  pus  in  the  medulla         bone;  B,  Lane 
.  .  plate;    C,  screws, 

to  dram  freely.    To  insure  free  draniage  the 

wound  is  packed  with  gauze,   and   to   clean  up   the  infection 

the  bone  and  wound   are   Dakinized  by  the  various  methods 

described  in  Chapter  XIX.     If  the  condition  is  complicated  by 

fracture,  the  limb  is  treated  by  suspension  and  traction,  plus 

the   Dakin   treatment. 

Because  of  the  hardness  and  unyielding  character  of  bone 
it  will  take  a  long  while  for  the  dead  bone  in  the  medulla  to 
form  a  line  of  demarcation  from  the  living,  and  that  is  why 
these  cases  of  osteomyelitis  linger  so  long  before  they  are  healed. 
The  dead  bone  which  often  comes  away  in  spicules  at  a  dress- 
ing, or  which  is  removed  at  some  subsequent  operation,  is  spoken 
of  as  a  sequestrum. 

Inasmuch  as  the  majority  of  these  cases  will  suffer  for  some 
time  from  a  continual  low  grade  toxemia,  it  is  important  to  look 
after  their  general  condition.     These  patients  should  be  given 


102  TEXTBOOK  OF  SURGICAL  NURSING 

as  miicli  fresh  air  as  possible,  kept  on  a  high  caloric  diet,  and 
although  confined  to  bed,  the  muscles  of  the  affected  limb  should 
be  given  daily  massage  whenever  possible.  This  will  insure 
proper  nourishment  and  maintain  muscle  tone,  for  it  is  well 
known  that  muscles  not  in  active  use  are  apt  to  undergo  atrophy. 
The  temperature  should  be  carefully  watched  and  any  sudden 
rise  might  be  indicative  either  of  retention  of  pus  somewhere 
in  the  wound,  or  the  starting  of  a  new  focus  in  the  same  bone  or 
another  one. 

Amputations. — Fortunately,  today,  amputations  are  but 
rarely  performed,  aud  limbs  which  years  ago  would  have  been 
sacrificed,  are  saved  now  by  the  newer  advances  of  surgical 
treatment.  Amputations  are  mutilations.  They  are  employed 
as  final  measures  and  their  indications  are  definitely  defined  and 
clearly  cut. 

Ante-operative  Treatment. — The  area,  through  which  the 
amputation  is  to  be  done  and  the  skin  for  a  considerable  dis- 
tance above  and  below,  should  be  shaven  and  cleansed  very  care- 
fully. If  there  are  any  open  sinuses  they  should  be  protected 
by  packing  and  sterile  dressings,  so  that  their  discharge  will  not 
contaminate  the  wound. 

To  prevent  hemorrhage  during  amputation  there  are  several 
methods  devised  which  aim  to  compress  the  blood  vessels  sup- 
plying the  limb  in  question. 

Esmarch's  Method.— This  method  attempts  to  squeeze  all  the 
blood  out  of  the  limb  by  applying  an  elastic  bandage  which  is 
wound  spirally  from  below  upward,  well  above  the  region  of 
amputation.  At  the  upper  limit,  an  ordinary  rubber  tubing 
tourniquet  is  applied  and  fastened.  The  elastic  bandage  is  then 
removed.  This  is  not  applicable  in  septic  conditions,  nor  in  cases 
of  tumors. 

Lister's  Method. — Here  the  limb  is  elevated  for  a  few  min- 
utes and  the  ordinary  tubing  applied  in  a  horizontal  fashion  as 
a  simple  tourniquet. 

Tourniquets. — These  should  always  be  applied  well  above  the 
region  to  be  amputated,  and  should  be  sterilized.  When  the 
amputation  is  to  be  done  near  the  hip  or  the  shoulder,  strips  of 
sterile  bandage  should  be  applied  around  the  tourniquets.   These 


NURSING  OF  THE  OSSEOUS  SYSTEM  103 

are  held  firmly  by  an  assistant  to  prevent  the  tourniquet  from 
slipping.  Some  surgeons  prefer  to  use  Wyeth's  pins,  elongated 
steel  pins  which  are  pierced  through  the  muscles,  and  the  tourni- 
quet in  pressing  against  these  is  prevented  from  sliding  off 
(Fig.  15). 

Amputation  Operation. — The  technic  of  the  operation  is 
variable.  Some  surgeons  will  inject  all  nerve  trunks  with  novo- 
cain before  cutting  them.  The  bone 
stump  is  treated  in  various  man- 
ners so  that  a  full  armamentarium 
of  bone  instruments  should  always 
be  on  hand.  Amputation  wounds 
are  usually  drained.  The  dressings 
applied  should  be  large  and  pres- 
sure should  be  evenly  exerted  either 
by  adhesive  strips  or  bandage.  As  a 

rule  the  stump  should  be  elevated.  -^       -^     ,^ 

Fig.   15. — Method  of  Ap- 

Sometimes  a  small  splint  is  applied    plying    Wyeth's   Pins.     A, 

.       ,1         ,  ,      .  IT        •,    •  Wyeth's  pins;    B,  tourniquet, 

to  the  stump  to  immobolize  it  m  a       "^  r      >      >  ^ 

more  efficient  manner. 

After  Treatment. — These  patients  are  apt  to  suffer  from  con- 
siderable shock  so  not  only  must  this  condition  be  watched  for, 
but  also  the  danger  of  secondary  hemorrhage.  It  should  be  rou- 
tine practice  to  have  an  emergency  tourniquet  set  very  near  the 
patient's  bed  so  that  should  bleeding  occur  no  time  may  be  lost 
in  arresting  the  hemorrhage.  If  the  oozing  is  marked,  the  dress- 
ing may  be  reinforced  or  changed  in  twenty-four  hours,  although 
it  is  better  to  wait  forty-eight  hours. 

Occasionally  when  the  wound  has  almost  healed  it  is  often 
necessary  to  apply  pressure  to  certain  flaps  or  skin  areas  to 
relieve  tension.  This  pressure  can  be  obtained  by  thin  bandaging 
or  by  adhesive  strappings.  In  bandaging,  it  is  always  to  be 
remembered  that  the  turns  which  pass  over  the  stump  should  be 
begun  from  above  downward  and  on  the  side  where  the  longer 
flap  is.  Sometimes  when  the  flaps  have  been  cut  too  short,  it 
may  be  necessary  to  apply  traction  to  pull  the  muscles  over  the 
stump. 


104  TEXTBOOK  OF  SURGICAL  NURSING 

While  the  stage  of  healing  is  in  progress,  gentle  massage  to 
the  muscle  groups  will  do  nuich  to  maintain  their  tone  and 
health. 

If  the  amputation  is  one  of  the  lower  extremity,  the  patient 
shduld  be  taught  carefully  the  proper  use  of  crutches.  Crutches 
should  not  press  into  the  axilla  but  the  weight  of  the  body  should 
be  sustained  by  the  hand  resting  on  the  cross  piece  of  the  crutch. 
Special  instructions  should  be  given  as  to  how  to  descend  and 
ascend  a  flight  of  stairs,  cautioning  the  patient  to  hold  the 
banister  with  one  hand  and  using  the  other  hand  to  hold  the 
supporting  crutch.  To  prevent  the  crutches  from  slipping  they 
should  always  be  equipped  with  rubber  tips. 


Chapter  viii 

THE    SURGERY   AJSTD    SURGICAL   NURSING    OF    THE 
REPRODUCTIVE    SYSTEM 

Composition. — The  genital  system  of  the  female  and  male 
may  he  divided  into  the  external  and  internal  organs  of  genera- 
tion. The  external  organs  in  the  female  consist  of  the  mons 
veneris,  the  external  opening  of  the  urethra,  the  clitoris,  the 
labia  majora,  labia  minora,  and  the  hymen ;  the  internal  organs 
are  the  vagina,  the  uterus,  the  tubes  and  ovaries.  In  the  male, 
the  external  organs  of  generation  are  the  penis,  the  scrotum 
which  contains  the  testis,  the  epididymis,  part  of  the  vas  defer- 
ens; the  internal,  the  prostate,  and  the  seminal  vesicles. 

Operations  on  Female  Genital  System. — The  operations  on 
the  female  genital  system  resolve  themselves  into  two  classes, 
those  which  are  external,  and  those  which  are  internal.  The 
external,  mainly  plastic  operations,  are  those  done  for  the  relief 
of  a  relaxed  perineum  or  lacerated  cervix,  injuries  which  follow 
tears  incident  to  childbirth.  A  weakened  pelvic  floor  may 
result  in  a  relaxation  of  the  anterior  vaginal  wall  with  a  subse- 
quent prolapse  of  the  bladder  (cystocele).  If  the  posterior  wall 
of  the  vagina  is  weakened,  a  prolapse  of  the  rectum  may  occur 
(rectocele).  Surgery  attempts  to  correct  the  cystocele  and 
rectocele  by  operations  upon  the  vagina  and  a  reconstruction  of 
the  muscles  of  the  perineum.  The  operations  come  under  the 
general  head  of  perineorrhaphy. 

Perineorrhaphy. — The  ante-operative  procedure:  The  vulva 
should  be  shaved,  scrubbed  with  green  soap  and  water,  then 
with  alcohol  and  ether.  It  is  advisable  to  catheterize  the  bladder 
routinely  in  all  these  cases.  The  patient  is  placed  in  a  lithotomy 
position  (see  Fig.  72,  page  277)  and  the  various  operations  for 
the  relief  of  the  pathological  conditions  are  performed.  The 
technic  of  the  operation  does  not  concern  us  here. 

Post-operative   Care. — Most  institutions  and  hospitals  have 

105 


106  TEXTBOOK  OF  SURGICAL  NURSING 

standard  perineorrhaphy  routines.  The  various  methods  are 
herewith  outlined : 

The  routine  which  the  nurse  will  follow  in  the  after  care  of 
a  perineorrhaphy  will  always  be  prescribed  by  the  surgeon ;  it 
will  vary  considerably  from  time  to  time,  depending  upon  the 
extent  of  the  wound  and  the  preferences  of  the  particular  sur- 
geon. In  any  case  it  is  extremely  important  to  keep  the  wound 
surgically  clean.  At  best,  the  task  is  not  easy,  nor  very  satisfac- 
tory because  of  the  necessary,  frequent  exposure  to  the  unsferile 
excretions  of  the  body.  Fortunately,  however,  nature  has  pro- 
vided this  part  of  the  body  with  unusual  resistance  to  infection, 
and  therefore  consistent  and  conscientious  teehnic  in  the  treat- 
ment of  a  perineorrhaphy  wound  will  be  rewarded  with  good 
results.  Some  surgeons  will  require  that  the  part  be  kept  iimno- 
bilized  for  at  least  the  first  forty-eight  hours.  This  is  accom- 
plished by  means  of  a  bandage  passed  about  the  thighs  binding 
the  legs  together.  This  will  be  particularly  desirable  in  the  case 
of  a  restless  patient.  Other  surgeons,  however,  will  not  pre- 
scribe this  treatment  and  the  nurse  will,  of  course,  not  administer 
it  as  a  routine  practice  because  it  is  a  rather  trying  ordeal  for 
some  patients.  When  applying  this  bandage  the  nurse  should 
remember  the  rule  forbidding  the  bandaging  together  of  any 
two  surfaces  of  skin  and  should  see  that  the  thighs  are  comfort- 
ably separated  by  means  of  a  layer  of  non-absorbent  cotton. 

Sometimes  catheterization  will  be  prescribed  to  avoid  contami- 
nation of  the  wound  by  the  urine.  This  may  be  for  only  a 
period  of  forty-eight  hours  at  stated  intervals,  or  it  may  be  for 
a  longer  time.  In  some  cases  treatment  will  be  directed  toward 
preventing  evacuation  of  the  bowels  for  a  stated  period,  some- 
times as  long  as  nine  days,  particularly  if  the  laceration  has 
been  a  complete  one — that  is,  one  which  has  extended  into  the 
rectum.  This  treatment  will  consist  of  opium  medication  to 
suppress  peristalsis,  of  fluid  diet  without  milk,  or  of  the  two 
combined.  Often,  however,  especially  in  cases  of  the  slighter 
wounds,  catharsis,  oil  enemas,  etc.,  will  be  given  in  the  course  of 
a  few  days.  Whatever  the  prescribed  general  treatment,  how- 
ever, the  nurse  must  follow  rigid  aseptic  teehnic  throughout. 
Catheterization,  of  course,  is  always  done  with  the  most  thorough 


NURSING  OF  THE  REPRODUCTIVE  SYSTEM     107 

asepsis,  so  no  special  lesson  will  be  necessary  here  as  to  that, 
except  to  point  out  that  in  this  case  the  asepsis  must  be  in  the 
interest  of  the  wound  as  well  as  the  bladder.  As  a  rule,  whether 
or  not  catheterization  is  done,  after  the  bladder  has  been 
emptied  the  perineum  will  be  douched  with  sterile  water  or  some 
mild  antiseptic  solution  such  as  2  per  cent,  boric  acid  or  1-5000 
bichloride,  which  will  be  allowed  to  flow  over  the  wound  from  a 
pitcher  or  irrigator.  The  wound  is  then  carefully  patted  dry 
with  sterile  gauze  and  the  prescribed  dressing  applied.  Some- 
times the  dressing  will  be  only  the  plain  dry  gauze ;  but  a  dust- 
ing powder,  such  as  aristol,  or  an  ointment,  such  as  boric  acid, 
may  also  be  applied.  Keeping  the  wound  dry  is  an  important 
part  of  the  nurse's  duty  in  this  case  and  it  will  require  careful 
manipulation  on  her  part  because  perineorrhaphy  sutures  are 
very  frequently  of  silkworm  gut  which  will  mean  that  they 
will  be  likely  to  catch  upon  dressings  and  involve  the  risk  of 
tearing  the  wound  and  also  of  causing  considerable  pain  to  the 
patient.  The  aseptic  precautions  will  be  necessary  at  least  till 
after  the  sutures  have  been  removed,  which  may  be  any  period 
of  from  fi^ve  to  ten  days. 

The  Uterus. — The  uterus  is  a  muscular,  pear-shaped  organ 
situated  in  the  pelvic  cavity  between  the  bladder  and  the  rectum. 
Its  normal  position  is  that  of  anteversion.  The  part  of  the 
uterus  which  projects  into  the  cavity  of  the  vagina  is  known 
as  the  cervix.  The  uterus  is  lined  with  mucous  membrane ;  and 
entering  the  fundus  or  body  of  the  uterus  are  the  openings  of 
the  Fallopian  tubes.  The  uterus  may  be  the  seat  of  acute  inflam- 
mations, malpositions,  or  new  growths,  either  benign  or  ma- 
lignant. 

Inflammations  of  the  Uterus. — The  mucous  membrane  of  the 
cervix  of  the  uterus  may  become  acutely  inflamed  due  to  a 
variety  of  causes,  especially  from  an  infection  by  the  gonococcus. 
This  condition  is  known  as  endocervicitis,  and  if  the  inflamma- 
tion extends  further  and  attacks  the  mucous  lining  of  the  uterus, 
the  process  is  known  as  endometritis.  The  treatment  of  this  con- 
dition may  be  either  medical  or  surgical. 

Treatment  of  Acute  Inflammatory  Conditions. — In  the  acute 
infections,  especially  those  due  to  a  gonorrhea  in  which  there 


108  TEXTBOOK  OF  SURGICAL  NURSING 

is  an  associated  iiretliritis  (inflammation  of  the  urethra)  and  a 
purulent  vaginal  discharge,  it  is  of  the  greatest  importance  to 
"warn  the  patient  of  the  severe  infeetiousness  of  the  disease,  and 
the  dire  results  which  follow,  if  it  is  willfully  neglected.  It  is 
imperative  that  the  hands  be  kept  away  from  the  eyes,  because 
a  gonorrheal  infection  of  the  organs  of  sight  may  cause  total 
and  permanent  blindness. 

The  patient  should  be  placed  in  bed,  given  a  bland  non-irri- 
tating diet  without  condiments  or  spices,  and  all  alcoholic  bever- 
ages absolutely  forbidden.  Fluids  should  be  forced  to  the 
utmost,  and  the  attending  nurse  should  give  copious  vaginal 
douches  everj'-  four  hours  with  any  silver  preparation,  either 
protargol  or  argyrol,  in  dilutions  of  1-10,000.  In  more  chronic 
stages,  these  may  be  followed  by  silver  nitrate  irrigations. 

Cervix. — The  cervix,  as  a  rule,  is  treated  by  the  surgeon  by 
direct  applications  of  10  to  20  per  cent,  silver  nitrate,  iodine,  or 
20  per  cent,  argyrol.  The  patient  is  appropriately  draped,  placed 
in  the  lithotomy  position,  a  bivalve  speculum  is  introduced,  and 
the  applications  made  directly  to  the  cervix.  However,  in  all 
these  treatments,  while  the  cervix  itself  may  be  benefited,  it  is 
difficult  to  reach  the  endometrium  or  lining  mucous  membrane 
of  the  uterus,  and  very  often  more  radical  surgical  procedures 
have  to  be  resorted  to. 

Operative  Treatment. — One  of  the  most  common  procedures 
is  the  operation  known  as  dilatation  of  the  cervix  and  curettage 
of  the  uterus.  The  purpose  of  the  dilatation  is  to  insure  suffi- 
cient stretching  of  the  cervical  canal,  so  that  instruments  may 
be  freely  passed  into  the  uterus,  and  secondly  to  insure  drainage 
of  the  uterine  cavity.  The  object  of  the  curettage  is  to  scrape 
away  the  diseased  mucous  membrane  of  the  uterus  so  that  a  new 
and  healthy  lining  will  replace  the  diseased  part.  While  this 
operation  is  done  for  chronic  inflammations,  it  is  also  performed 
for  the  retained  membranes  of  pregnancy,  and  for  incomplete 
abortions.  It  is  also  a  diagnostic  measure,  for  in  doubtful  cases 
of  cancer  of  the  uterus,  the  curettings  may  be  examined  for 
microscopic  evidences  of  malignancy. 

There  are  cases  in  which  there  is  a  definite  stenosis,  or  narrow- 
ing   of    the    cervix,    resulting    in    very    painful    menstruation 


NURSING  OF  THE  REl^RODlUm  VK  SYSTEM      109 

(dysmenorrhea)  and  often  in  sterility.  In  order  to  insure  a 
permanent  opening  of  tlie  cervical  canal,  after  operative  dilata- 
tion, a  stem-pessary  of  either  glass  or  rubber  is  often  sewed  in 
the  cervical  canal,  and  permitted  to  remain  in  place  until  the 
appearance  of  the  next  period.  While  the  stem-pessary  is 
within  the  cervix,  a  daily  douche  of  disinfectant  variety  should 
be  administered,  as  the  mechanical  presence  of  the  foreign  body 
generates  a  certain  amount  of  disagreeable  discharge. 

When  the  cervix  is  badly  torji,  the  laceration  may  become  a 
source  of  irritation.  A  plastic  repair  is  often  done ;  the  opera- 
tion being  known  as  trachelorrhaphy.  When  the  tears  are 
multiple  it  may  be  necessary  to  amputate  the  cervix  partially 
or  completely. 

Malpositions  of  the  Uterus. — While  the  normal  position  is 
that  of  anteversion,  the  uterus  may  occupy  a  backward  posi- 
tion. This  is  spoken  of  as  retroversion.  Naturally  there  are 
many  women  who  suffer  from  retroversion  without  symptoms, 
but  if  backache  and  other  reflex  symptoms  are  severe,  the  uterus 
must  be  replaced.  The  replacement  will  be  dependent  upon  the 
movability  of  the  uterus.  The  uterus  may  be  replaced  sometimes 
by  manual  manipulations  by  the  surgeon  with  the  patient  in  the 
knee-chest  position.  Should  the  procedure  prove  too  painful, 
because  of  inflammatory  products  binding  the  uterus  to  other 
structures,  hot  vaginal  douches  may  be  ordered  twice  daily, 
after  which  the  patient  is  instructed  to  assume  the  knee-chest 
position  for  periods  of  from  five  to  ten  minutes,  night  and  morn- 
ing. This  often  diminishes  the  inflammation  to  such  a  degree 
that  manipulations  on  the  part  of  the  doctor  are  less  painful 
and  more  successful.  After  the  uterus  has  been  replaced  it  may 
be  held  in  position  by  pessaries.  These  are  appliances,  usually 
of  hard  rubber,  of  various  forms,  which  are  introduced  into  the 
vagina  with  the  object  of  exerting  pressure  so  as  to  hold  the 
uterus  in  place.  Pessaries  must  never  be  sterilized  by  boiling 
because,  if  they  are  made  of  rubber,  boiling  alters  their  shape. 
If  the  uterus  cannot  be  brought  back  by  these  measures,  opera- 
tive procedures  must  be  resorted  to. 

Operations  for  Retroversion. — The  purpose  of  all  operative 
procedure  is  to  bring  the  uterus  forward  and  upward  to  its 


110  TEXTBOOK  OF  SURGICAL  NURSING 

normal  anatomical  position  and  to  hold  it  securely  there.  In 
the  majoi'ity  of  operations  this  is  accomplished  hy  shortening 
the  round  ligaments.  The  operation  may  be  performed  through 
the  inguinal  canals,  through  the  abdomen,  and  through  the 
vagina. 

The  inguinal  canal  route : — As  the  round  ligaments  help  to 
maintain  the  normal  position  of  anteversion,  they  may  be  iso- 
lated in  the  inguinal  canal,  drawn  out  and  sufficiently  shortened 
so  as  to  exert  tension,  and  thus  mechanically  pull  tlie  uterus 
forward  into  place. 

The  abdominal  route: — The  uterus  is  lifted  from  its  retro- 
verted  position  and  the  fundus  is  sutured  to  the  anterior  abdom- 
inal wall  directly  (ventral  fixation).  Or  the  round  ligaments 
are  sutured  to  the  recti  muscles  (the  so-called  Gilliam  operation 
of  ventral  suspension). 

The  vaginal  route: — The  patient  is  placed  in  a  lithotomy 
position,  and  the  operation  done  through  the  vagina.  The  uterus 
is  brought  forward  by  suturing  either  to  the  anterior  vaginal 
wall,  or  the  lower  part  of  the  bladder,  or  it  is  pulled  into  place 
by  shortening  the  round  ligaments. 

Prolapse  of  the  Uterus. — This  condition  is  often  called  "fall- 
ing of  the  womb."  Prolapse  of  the  uterus  is  divided  into  three 
degrees.  The  first  degree  is  that  in  which  there  is  a  relaxation 
of  the  pelvic  floor  with  a  protrusion  of  the  vaginal  walls ;  in  the 
second  degree,  the  cervix  is  found  at  the  vulva ;  and  in  the  third 
degree  there  is  a  mass  of  the  uterus  protruding  from  the  vagina 
and  lying  between  the  thighs. 

Treatment  of  Prolapse. — The  palliative  measures  are  the  use 
of  pessaries  and  tampons.  A  large  circular  rubber  ring  in  the 
vagina  is  often  very  efficacious  in  maintaining  the  uterus  in 
position.  It  is  highly  important  that  these  pessaries  be  removed 
at  least  once  a  month  and  cleaned,  and  at  the  same  time  the 
vaginal  canal  be  inspected  to  determine  whether  any  irritation 
is  present. 

The  curative  measure  is  operation.  The  uterus  is  brought 
forward  and  upward  by  a  ventral  fixation  and  a  perineorrhaphy 
gives  support  below.  In  some  cases  it  is  often  advisable  to 
remove  the  uterus   (hysterectomy). 


NURSING  OF  THE  REPRODUCTIVE  SYSTEM     111 

Tumors  of  the  Uterus. — The  uterus  may  give  origin  to  benign 
and  malignant  growths.  The  most  common  benign  tumor  is  a 
fibroid.  These  may  cause  bleeding  (menorrhagia),  vaginal  dis- 
charge, pain,  and  quite  often  a  mass  may  be  felt  within  the 
abdomen.  However,  there  are  many  women  who  have  fibroids 
which  never  cause  symptoms.  Fibroids  are  treated  by  X-ray, 
radium,  and  operation. 

Operative  Treatment. — If  the  fibroids  are  single  and  do  not 
involve  the  entire  uterus,  the  tumor  may  be  enucleated 
(myomectomy).  If  the  tumors  are  multiple  and  involve  most 
of  the  uterus,  the  entire  organ  may  be  removed  (hysterectomy). 
This  is  an  operation  designed  to  remove  the  uterus.  It  may  be 
performed  through  the  abdomen  (supravaginal  hysterectomy), 
or  it  may  be  done  through  the  vagina  (vaginal  hysterectomy). 

Supravaginal  Hysterectomy. — After  the  patient  is  anes- 
thetized, she  is  placed  in  an  exaggerated  Trendelenburg  position. 
(Fig.  63,  page  271.)  The  abdomen  is  opened  by  a  median  incision 
and  the  intestines  are  carefully  padded  off  with  warm,  moist 
saline  pads.  The  fundus  of  the  uterus  is  seized  with  a  vulsellum. 
The  broad  ligaments  on  each  side  are  clamped,  and,  if  possible, 
one  of  the  ovaries  is  left.  The  uterovesical  fold  of  the  peritoneum 
is  incised  and  dissected  toward  the  bladder.  The  uterine  arteries 
are  then  clamped  and  the  uterus  is  amputated  through  the 
cervix.  The  cervical  stump  is  grasped  with  a  second  vulsellum, 
and  the  cervical  canal  is  cauterized  with  carbolic  acid  or  iodine. 
The  cervix  is  then  united  in  interrupted  sutures,  and  the  vessels 
usually  tied  with  plain  gut.  The  round  ligaments  are  sutured  to 
the  cervical  stump  and  the  pelvic  peritoneum  approximated  to 
the  pelvic  peritoneum.  This,  of  course,  leaves  a  little  cervical 
tissue  which  may  cause  a  persistent  leukorrhea.  To  avoid  this 
the  entire  cervix  may  be  extirpated. 

When  the  pelvic  operation  has  been  completed,  the  patient 
should  be  returned  to  the  horizontal  position  and  the  abdominal 
wall  closed.  Occasionally  vaginal  drainage  is  required.  This 
is  done  before  the  abdomen  is  closed  by  passing  a  curved  clamp 
into  the  vagina  and  pressing  against  the  posterior  vaginal  wall 
behind  the  cervix.    The  surgeon  incises  this  area  and  introduces 


112  TEXTBOOK  OF  SURGICAL  NURSING 

a,  cigarette  drain  into  the  elanip.  When  this  is  withdrawn,  the 
drain  is  })ulled  down  into  the  vagina. 

There  is  no  special  nursing  required  post-operatively  except 
that  a  careful  watch  should  be  kept  for  hemorrhage.  Occasion- 
ally, although  fortunately  rarely,  a  ligature  slips,  and  an  uterine 
artery  will  start  to  bleed.  This  requires  immediate  surgical 
interference.  Patients,  as  a  rule,  are  kept  in  bed  for  about 
sixteen  days. 

Vaginal  Hysterectomy. — This  is  performed  through  the 
vagina  without  an  abdominal  incision.  It  has  no  advantage  over 
the  other  except  that  it  does  not  leave  a  scar. 

Malignant  Diseases  of  the  Uterus. — These  may  either  affect 
the  cervix  or  the  body  of  the  uterus.  They  are  usually 
carcinomatous  in  character.  The  treatment  is  either  complete 
hysterectomy,  or  tlie  application  of  radium. 

Diseases  of  Fallopian  Tubes. — Any  inflammation  of  the  Fal- 
lopian tubes  is  spoken  of  as  salpingitis.  It  may  be  acute  or 
chronic. 

Acute  Salpingitis. — This  may  be  due  to  an  infection  occurring 
during  labor,  from  unclean  instruments,  much  instrumentation, 
or  a  preexisting  gonorrheal  infection.  The  history  usually  given 
is  that  of  a  vaginal  discharge,  abdominal  pain  of  a  colicky  nature 
and,  in  addition,  the  history  of  a  recent  labor,  instrumentation, 
or  gonorrhea. 

Treatment. — The  treatment  consists  of  absolute  rest  in  bed 
in  the  Fowler's  position  (Chapter  IV,  page  59).  Hot  vaginal 
douches  are  given  every  six  to  twelve  hours  depending  upon  the 
severity  of  the  inflammation.  Applications  are  made  to  the 
lower  abdomen,  either  in  the  form,  of  heat  or  cold,  and  move- 
ments of  the  bowels  should  be  assured  by  enemas.  If  the  pain 
is  ver}'-  severe,  sedatives  may  be  given.  Very  often  these  cases 
of  tubal  infection  are  complicated  by  pelvic  peritonitis  resulting 
in  the  development  of  a  pelvic  abscess.  Instead  of  draining  this 
through  the  abdomen,  the  abscess  may  often  be  drained  through 
the  vagina  by  making  an  incision  between  the  posterior  part  of 
the  cervix  and  the  posterior  wall  of  the  vagina.  This  is  knowr^ 
as  a  colpotomy.  A  good  sized  drainage  tube  is  introduced  into 
the  abscess  cavity,  but  because  of  the  dependent  position,  the 


NURSING  OF  THE   REPRODIJCTIVE  SYSTEM     113 

drainage  tube  will  not  stay  in  place  without  some  special 
arrangement  of  a  cross  piece,  so  as  to  make  a  "T"  tube.  Great 
care  should  be  taken  that  the  vagina  is  kept  scrupulously  clean, 
and  the  drainage  free.  To  accomplish  this,  vaginal  irrigations 
with  normal  saline  solution  should  be  given  twice  a  day. 

Chronic  Salpingitis. — This  may  be  a  sequel  of  acute  salpin- 
gitis. The  tube  may  either  be  bound  down  with  fibrous  adhe- 
sions, or  it  may  be  dilated  and  filled  with  watery  material 
(hydrosalpinx);  or  it  may  be  filled  with  pus  (pyosalpinx). 
Occasionally  it  may  be  tuberculous. 

Symptoms  and  Treatment. — The  symptoms  are  backache, 
pain  in  the  lower  abdomen,  menstrual  disturbances,  weakness, 
and  vaginal  discharge.  Physical  examination  may  reveal  a  mass 
in  the  pelvis.  If  the  case  is  adjudged  favorable  for  operation, 
a  low  laparotomy  is  performed  with  the  excision  of  the  affected 
tube  (salpingectomy).  There  are  no  special  ante-operative  or 
post-operative  measures  other  than  those  which  have  been  out- 
lined in  all  other  abdominal  operations. 

Ectopic  Pregnancy. — The  ovum  is  normally  fertilized  in  the 
tube,  and  it  continues  its  journey  until  it  reaches  the  uterine 
cavity  where  it  becomes  implanted,  and  proceeds  to  develop. 
Occasionally,  however,  the  fertilized  ovum  becomes  arrested  in 
the  tube  tind  begins  its  development  in  this  location.  This  is 
spoken  of  as  an  ectopic  gestation.  The  degree  to  which  the  tube 
may  increase  in  diameter  because  of  the  growing  ovum  is  limited. 
The  result  is  that  it  ruptures,  causing  the  death  of  the  embryo, 
and  hemorrhage  from  the  tube.  This  bleeding  is  a  source  of 
great  danger  to  the  mother  because  it  may  result  in  death. 

Symptoms. — The  history,  as  a  rule,  is  that  of  delayed 
menstruation.  The  patient  is  seen  generally  after  the  tubal 
rupture.  This  gives  rise  to  sharp  pains  localized  in  the  lower 
abdomen,  and  fainting  spells  due  to  the  loss  of  blood.  If  the 
hemorrhage  is  marked,  the  patient  will  exhibit  all  its  charac- 
teristic signs. 

Treatment. — Immediate  operation  is  indicated,  for  the  bleed- 
ing from  the  tube  must  be  stopped  by  salpingectomy,  and  the 
tubal  branch  of  the  ovarian  artery  ligated.  The  free  blood  in 
the  pelvis  is  removed  by  sponging  or  aspiration  through  suction. 


114  TEXTBOOK  OF  SURGICAL  NURSING 

Post-operative  Care. — As  these  patients  are  suffering,  as  a 
rule,  from  loss  of  tluid,  saline  is  given  intravenously,  and,  as 
soon  as  possible,  a  blood  transfusion.  They  are  kept  warm  like 
other  shocked  patients,  but  if  it  can  be  avoided,  the  shock  posi- 
tion is  not  used.  As  soon  as  they  have  recovered  sufficiently  tliey 
are  placed  in  the  Prowler  position.  Cleans  are  taken,  as  soon 
as  practical,  to  increase  their  red  blood  cells  by  the  use  of 
tonics,  and  the  administration  of  iron  in  the  form  of  Blaud's 
pills. 

The  Ovary. — The  ovary  besides  secreting  the  ovum  possesses 
an  internal  secretion  which  exercises  a  very  important  part  in 
maintaining  the  normal  nervous  mechanism  of  the  individual. 
Removal  of  both  ovaries  results  in  the  complete  cessation  of 
menstruation  and  a  train  of  ner\'ous  symptoms  which  make 
these  patients  objects  of  pity.  They  become  very  excitable, 
nervous,  melancholy,  and  often  so  desperate  that  they  have 
ended  their  existence  by  suicide.  It  is  now  the  custom,  when- 
ever possible,  to  leave  some  part  of  the  ovarian  tissue,  and  should 
it  be  absolutely  necessary  to  remove  all  of  it,  as  in  radical  pan- 
hysterectomies for  cancer  of  the  uterus,  the  patient  may  be  fed 
the  ovarian  extract  of  the  animal.  It  is  surprising  what  good 
results  will  follow. 

Diseases  of  the  Ovary. — Ovaritis  is  an  inflammation  of  the 
ovary,  rarely  primarily  diseased  but  usually  secondary  to  tubal 
inflammation,  which  results  in  adhesions  between  both  structures 
producing  a  condition  spoken  of  as  ''diseased  adnexa"  or  sal- 
pingo-oophoritis.  The  symptoms  are  similar  to  those  of  salpin- 
gitis and  the  treatment  employed  is  the  same. 

New  Growths. — Cysts. — More  than  any  other  organ,  the 
ovary  is  apt  to  give  rise  to  cysts  and  c^'stic  degeneration.  The 
cysts  may  be  of  small  size,  or  grow  to  enormous  dimensions 
weighing  more  than  twenty  pounds.  They  may  be  filled  with  a 
clear  viscid  fluid  or  with  other  cellular  materials.  Types  of  the 
last  named  variety  are  occasionally  called  cystadenomas.  Cer- 
tain of  these  tumors,  if  their  contents  are  spilled  over  the  peri- 
toneal cavity,  will  cause  secondary  tumors  acting  much  like 
malignant  growths. 

Dermoid  Cyst. — These  are  tumors  which  contain  remnants 


NURSING  OF  THE  REPRODUCTIVE  SYSTEM     115 

of  the  epidermis,  such  as  hair;  in  addition  bone  is  often  found 
as  well  as  other  tissues. 

Carcinoma. — The  ovary  may  be  the  seat  of  carcinomatous 
tissue  and  cancers  of  the  ovary  are  frequently  malignant, 
metastasizing  early. 

Treatment  of  Cysts. — In  the  case  of  simple  cysts,  only  part 
of  the  ovary  affected  may  have  to  be  removed,  or  if  the  entire 
ovary  is  filled  with  many  small  cysts,  a  complete  oophorectomy 
may  be  performed.  It  is  highly  important  that  cysts  of  the  ovary 
be  delivered  intact.  Every  effort  should  be  made  to  preserve 
their  integrity,  for  occasionally  a  cyst  may  be  of  the  adenomatous 
variety,  and  if  accidentally  ruptured,  the  fluid  escapes  into  the 
general  peritoneal  cavity  and  implantation  growths  take  root. 

In  carcinoma  of  the  ovary,  the  treatment,  of  course,  is  extirpa- 
tion with  subsequent  X-ray  or  radium  treatment.  The  general 
outlook  of  patients  with  ovarian  carcinoma  is  indeed  poor. 

The  Testicle. — This  is  the  male  organ  of  generation  and  cor- 
responds to  the  ovary.  It  consists  of  the  testes  proper  which 
manufacture  the  spermatozoa,  and  the  epididymis  which  is 
really  a  series  of  canals  collecting  the  sperm  from  the  glandular 
substance  of  the  testes.  These  tubules,  or  canals,  unite  to  form 
a  single  duct,  the  vas  deferens,  which  carries  the  testicular 
product  to  the  seminal  vesicles,  small  pouches  situated  behind 
the  prostate  which  open  into  the  floor  of  the  prostatic  urethra 
together  with  the  openings  of  the  prostate  gland.  The  prostate 
gland  lies  in  front  of  the  bladder  surrounding  the  prostatic 
urethra  and  secretes  the  fluid  which  nourishes  the  spermatozoa 
and  gives  the  seminal  fluid  its  characteristic  qualities. 

While  the  great  majority  of  these  cases  will  be  handled  by 
orderlies  and  trained  attendants,  circumstances  may  arise  which 
will  necessitate  that  they  be  cared  for  by  skilled  nurses. 

Acute  Inflammation  of  Testicle  and  Epididymis. — Probably 
the  most  common  cause  of  the  acute  inflammation  is  gonorrhea 
affecting  the  epididymis  mainly,  although  it  may  be  secondary 
to  certain,  chronic  diseases  such  as  gout,  or  trauma  from  urethral 
instrumentation. 

Symptoms. — There  are  pain,  swelling,  tenderness  of  the  epi- 


116  TEXTBOOK  OF  SURGICAL  NURSING 

didymis,  and  systemic  symptoms  of  anorexia,  fever,  and  general 
malaise. 

Treatment. — The  patient  is  ordered  to  bed,  and  the  testicle 
is  elevated  by  plaeinfi:  beneath  the  scrotum  broad  strips  of  adiie- 
sive  plaster  which  are  fastened  to  the  shaven  thighs.  Local 
applications  to  the  scrotnm  may  be  made  in  the  form  of  heat  or 
cold.  Probably  the  application  bearing  heat  which  is  lightest 
in  weight  is  the  flaxseed  poultice.  If  ice  is  nsed  it  should  not  be 
left  on  continuously,  but  on  for  two  hours  and  off  for  one.  An 
enema  should  be  given  daily,  and  the  patient  forced  to  drink 
water  in  large  amounts.  AVlien  the  condition  is  due  to  gonorrhea, 
the  patient  should  be  placed  upon  individual  precaution.  After 
the  acute  symptoms  have  subsided,  the  patient  may  be  allowed 
up,  but  the  scrotum  should  be  firmly  supported  by  a  suspensory 
for  some  time. 

Chronic  Inflammation  of  Testicle  and  Epididymis. — These  are 
secondary  to  acute  inflammations,  or  due  to  syphilis  or  tuber- 
culosis. If  syphilitic  in  nature  the  patient  is  given  antisyphilitic 
treatment  in  the  form  of  mercury  and  salvarsan.  If  tuberculous, 
the  best  procedure  is  operative. 

Symptoms. — The  pain  is  not  so  severe  as  in  acute  inflamma- 
tions. In  the  cases  of  tuberculosis,  there  may  be  a  sinus  in  the 
scrotum  discharging  pus  from  the  diseased  epididymis. 

Treatment  of  Tuberculosis. — Tuberculous  epididymitis,  when 
only  one  side  is  involved,  is  treated  by  orchidectomy  (excision 
of  the  affected  testicle).  These  cases  require  no  special  nursing 
(care  except  that  they  should  be  placed  upon  individual  precau- 
tions and  kept  out  in  the  open  air  as  much  as  possible. 

Hydrocele. — Lying  in  front  of  the  testis  and  epididymis  there 
is  a  small  sac  called  the  tunica  vaginalis.  This  may  become  filled 
with  fluid  causing  a  hydrocele  of  the  tunica  vaginalis.  As  a  rule 
it  is  not  painful  but  uncomfortable  because  of  its  mere  mechan- 
ical presence. 

Palliative  Treatment. — In  this  procedure  a  needle  or  a  trocar 
and  canula  are  inserted  into  the  hydrocele  sac  and  the  fluid 
withdrawn.  After  most  of  the  water  has  been  tapped,  some 
surgeons  reinject  an  irritathig  fluid,  such  as  a  mild  solution 


NURSING  OF  THE  REPRODTICTTVE  SYSTEM     117 

of  carbolic  and  iodine,  trusting  that  tlie  irritation  will  cause  the 
obliteration  of  the  sac  of  the  tunica  vaginalis. 

Operative  Treatment. — The  operative  procedure  may  be  done 
under  novocain.  The  scrotum  is  washed  with  green  soap,  alco- 
hol and  ether.  The  skin  of  the  scrotum  is  anesthetized.  The  dis- 
tended tunica  is  delivered  into  the  wound,  incised,  part  of  it 
cut  away,  and  the  remainder  sutured  behind  the  testicle  proper, 
destroying  the  sac. 

Post-operative  Treatment. — The  scrotum  is  supported  upon 
a  bridge  and  a  moderate  amount  of  pressure  is  applied  to  it  to 
prevent  post-operative  bleeding. 

Varicocele. — Lying  in  the  scrotum  along  with  the  spermatic 
cord  is  a  plexus  of  veins.  These  very  often  become  hypertrophied 
or  increased  in  size  and  number,  occasionally  causing  pain  and 
a  dragging  sensation  in  the  scrotum.  This  may  be  remedied  by 
partially  excising  the  veins  through  the  scrotum,  or  just  above 
the  external  abdominal  ring.  The  only  post-operative  care  is 
the  support  of  the  testicles  by  an  adhesive  bridge,  and  the  wear- 
ing of  a  suspensory  bandage  subsequently. 

New  Growths  of  Testicle: — The  testicle,  like  the  ovary,  may 
be  a  location  for  cysts,  spermatocele,  dermoids,  or  carcinoma. 
In  the  cases  of  cancer,  a  radical  excision  of  the  testicle  together 
with  the  vas  deferens  and  the  lymph  glands  draining  these 
regions  is  performed  but  the  operation  is  attended  with  very 
much  shock,  and  the  mortality  is  extremely  high. 

Prostate. — One  of  the  most  common  operations  done  upon 
the  male  genital  tract  is  that  of  prostatectomy,  removal  of  the 
prostate  gland.  This  is  performed  for  simple  hypertrophy,  or 
for  cancer.  It  is  known  that  the  prostate  consists  mainly  of  three 
lobes,  the  middle  coming  into  close  relationship  with  the  urethra 
and  the  lateral  lobes  coming  into  relationship  with  the  rectum. 
When  the  prostate  increases  in  size,  it  follows  the  path  of  least 
resistance  and  projects  into  the  bladder,  and  the  increase  in  the 
size  of  the  median  lobe  interferes  with  the  free  passage  of  urine 
because  it  obstructs  the  internal  opening  of  the  urethra.  This 
results  in  frequency  of  urination,  then  urinary  retention  which 
must  be  relieved  by  a  catheter,  and  from  frequent  catheteriza- 
tions  a  condition  of  cystitis  is  very   often   established.     The 


lis  TEXTBOOK  OF  SURGICAL  NURSING 

suffering  is  quite  severe,  and  the  only  measure  affording  perma- 
nent relief  is  the  removal  of  the  obstruction  (prostatectomy). 

Prostatectomy. — This  operation  is  often  preceded  by  a  period 
of  improving  the  patient's  nutrition,  and  his  urinary  output  by 
regular  catheterizations.  The  operation  resolves  itself  into  a 
choice  of  perineal  or  suprapubic  prostatectomy. 

Perineal  Prostatectomy. — The  perineum  is  shaved  and  eight 
hours  before  operation  the  usual  soapsuds  enema  is  given. 
The  patient  is  placed  in  a  lithotomy  position  with  the  pelvis 
raised  by  sandbags  and  the  prostate  is  enucleated  through  the 
perineum. 

Post-operative  Treatment. — The  retained  catheter  is  con- 
nected to  bottle  drainage  and  the  urine  collected.  The  gauze 
tampon  which  usually  occupies  the  space  of  the  removed  pros- 
tate is  taken  out  on  the  fifth  day;  the  catheter  is  removed  on 
the  seventh,  and  from  then  on  the  urethra  is  treated  with  sounds 
of  various  sizes. 

Suprapubic  Prostatectomy. — In  this  procedure  the  prostate 
is  removed  through  the  bladder.  It  is  done  in  two  stages.  The 
first  operation  is  a  suprapubic  cystotomy,  the  second  the  actual 
removal  of  the  gland   through   the  previous  bladder  wound. 

First  Stage: — As  a  rule,  catharsis  is  given  forty-eight  hours 
previous  to  the  day  of  operation.  Before  operation  the  bladder 
is  irrigated  and  often  some  novocain  or  alypin  is  injected.  The 
bladder  is  kept  distended  and  the  cystotomy  is  done  under  local 
anesthesia.  A  button  drainage  tube  is  placed  in  the  opening  of 
the  bladder  and  the  tube  clamped.  When  the  patient  arrives  in 
his  room  the  clamp  should  be  removed  from  the  tube  and  the 
bladder  drained  continuously,  or  intermittently.  The  diet 
should  be  very  light  and  soft,  fluids  allowed  in  liberal  amounts. 

Second  Stage: — While  some  surgeons  proceed  to  enucleate 
the  prostate  immediately  after  cystotomy,  the  majority  wait 
five  or  more  days  before  completing  the  operation.  Naturally 
there  will  be  rather  a  profuse  hemorrhage  following  the  blunt 
dissection  of  the  gland.  This  may  be  controlled  by  tampons, 
but  a  better  result  is  obtained  if  a  bag  hemostat  is  used.  This  is 
made  of  rubber,  is  inflatable  and  when  distended  and  placed 
within  the  bladder  exerts  pressure  on  the  bleeding  areas.    One 


NURSING  OF  THE  REPRODUCTIVE  SYSTEM     119 

connection  of  the  bag  passes  through  the  urethra,  and  is  the 
means  by  which  air  is  introduced.  This  is  removed  in  twenty- 
four  to  forty-eight  hours. 

The  suprapubic  wound  is  freely  drained,  and  at  the  end  of 
forty-eight  hours  a  button  tube  is  inserted,  connected  to  the 
bottle  drainage  and  the  patient  allowed  out  of  bed.  At  the 
end  of  a  week  the  patient  is  encouraged  to  void,  and  as  soon  as 
he  does  so  in  sufficient  amounts,  the  suprapubic  tube  is  removed. 
Of  course,  the  urine  will  leak  in  small  amounts,  but  the  sinus  is 
healed  in  from  the  thirteenth  to  the  twentieth  day. 

Cancer  of  Prostate.— In  the  early  stages  this  is  treated  by 
prostatectomy.  In  the  late  periods,  radium  is  tried  as  a  pallia- 
tive procedure. 


CHAPTER  IX 

THE    SURGERY    AND    SURGICAL    NURSING    OF    THE 
RESPIRATORY  SYSTEM 

The  organs  which  constitute  the  respiratory  system  may  be 
classified  as  the  accessory  and  the  main  groups. 

rnares 
Accessory  System:     1.  Nose -I  septum 

[sinuses 

2.  Mouth 

f  nasopharynx 

3.  PhaiTnx|^^^pj^^^y^ 

Main  System:  1.  Larynx 

2.  Trachea 

3.  Bronchi 

4.  Lungs  and  Pleura 

The  mouth  and  pharynx  are  discussed  under  the  Alimentary 
System. 

Nose. — The  nose  serves  the  very  important  function  of  filter- 
ing, warming,  and  moistening  the  air.  In  addition  to  aiding 
the  sense  of  smell,  it  also  gives  the  voice  some  of  its  qualities. 
The  diseases  which  affect  the  nose  are  many  and  well  known. 
The  only  pathological  conditions  of  interest  here  are  those 
resulting  from  obstruction  from  a  deviated  septum  or  hyper- 
trophy of  the  turbinates  (bones  in  the  nares)  and  infections 
of  the  various  sinuses. 

Deviated  Septum. — In  this  condition  one  or  both  sides  of  the 
nose  are  occluded  by  a  deformity  of  the  nasal  septum,  and  an 
attempt  is  made  to  remove  the  obstructing  cartilage  by  a  sub- 
mucous resection  preserving  the  mucous  membrane  of  the  sep- 
tum. After  the  operation  has  been  completed,  each  nasal  cavity 
is  packed,  with  strips  of  sterile  gauze.  The  packing  is  removed 
after  twenty-four  hours. 

120 


NURSING  OF  THE  RESPIRATORY  SYSTEM      121 

Hypertrophy  of  the  Turbinates. — The  turbinates  are  small 
bones,  three  in  number,  found  along  the  outer  wall  of  each  nasal 
cavity.  Occasionally  these  increase  in  size  and  obstruct  free 
respiration.  They  may  be  reduced  by  chemical  irritants,  cautery, 
or  partially  removed  by  cutting  them  with  a  wire  snare.  Occa- 
sionally, hemorrhage  may  follow  the  removal  of  part  of  the  turbi- 
nate bones.  This  may  be  controlled  by  spraying  in  some  adrena- 
lin solution,  syringing  the  nose  with  hot  water  (temperature 
about  120  degrees)  or  plugging  the  nose  with  cotton.  Most  of 
these  operations  are  done  under  novocain. 

Sinusitis. — The  sinuses  of  the  nose  may  be  frequently  in- 
volved during  a  cold,  and  very  often  the  frontal,  ethmoidal, 
sphenoidal  sinuses,  or  the  antrum  may  be  the  seat  of  infection. 
This  condition  is  recognized  by  pain  in  the  region  of  the  sinus 
involved,  discharge,  and  tenderness  on  pressure  over  the  sinus. 
The  treatment  consists  in  establishing  free  drainage.  In  the 
case  of  the  antrum  of  Highmore,  this  is  done  by  punctures  of 
the  sinus  and  daily  irrigations  through  the  nose. 

The  Larynx. — Those  conditions  affecting  the  larynx  which 
are  of  interest  from  a  surgical  viewpoint  may  be  divided  into 
the  foreign  bodies  lodged  in  the  larynx,  and  new  growths.  There 
are  many  other  conditions,  such  as  acute  and  chronic  inflamma- 
tions, syphilis  and  tuberculosis,  which  require  attention,  but 
they  fall  into  the  provinces  of  the  laryngologist,  and  he  person- 
iilly  gives  most  of  the  necessary  treatments. 

Foreign  Bodies. — The  most  common  way  for  foreign  bodies 
to  lodge  either  in  the  larynx,  or  further  down  in  the  trachea,  is 
for  the  individual  to  swallow  them.  The  symptoms  which  are 
produced  will  vary  according  to  the  size  of  the  body  and  its 
location  in  the  respiratory  tract.  Sometimes  they  are  expelled 
by  coughing;  at  other  times  they  may  remain.  Cases  are  not 
rare  in  which  the  material  has  been  of  sufficient  bulk  to  occlude 
the  larynx,  with  death  immediately  ensuing  from  asphyxiation. 

Treatment. — Slapping  the  patient  on  the  back,  or  inverting 
him  may  dislodge  the  foreign  body.  Or,  if  the  patient  is  not 
so  fortunate,  it  may  be  removed  with  forceps  under  direct  vision, 
or  either  a  Killian  or  Jackson  laryngoscope  may  be  necessary. 
These    are    instruments   designed    to    enter   the    larynx.      The 


122  TEXTBOOK  OF  SURGICAL  NURSING 

pharynx  and  larynx  may  be  (.'ocainized,  or  the  patient  may  be 
placed  under  deep  anestliesia.  The  laryngoscope  is  passed 
throngh  the  month  and  jiliarynx  into  the  larynx^  the  head  and 
neck  being  bent  baek^vard,  and  the  foreign  body  removed 
through  the  instrument. 

Occasionally,  the  condition  is  so  urgent  that  to  relieve  the 
asphyxia,  an  opening  must  be  made  into  the  trachea  below  the 
point  of  obstruction,  so  that  air  may  enter  the  lungs.  This 
opening  of  the  trachea  is  spoken  of  as  tracheotomy. 

Tracheotomy. — A  tracheotomy  is  an  incision  into  the  trachea 
in  order  that  a  tube  may  be  introduced  therein,  thus  pro- 
viding for  the  entrance  and  exit  of  air.  This  may  be  done  either 
as  an  emergency  measure  following  a  thyroid  operation  in  which 
the  trachea  has  collapsed,  when  a  foreign  body  has  become  lodged 
in  the  larynx  so  that  respiration  is  embarrassed,  in  acute  edema 
of  the  glottis,  or  in  obstruction  asphj-xia  during  the  adminis- 
tration of  an  anesthetic.  It  may  be  employed  as  a  preliminary 
measure  to  a  removal  of  the  larynx  for  cancer.  The  operation 
is  either  high  or  low,  the  high  being  preferable,  because  the 
trachea  is  more  accessible ;  the  low  being  done  when  the  operator 
has  to  reach  a  foreign  body  which  has  fallen  into  one  of  the 
bronchi. 

Operation. — The  patient  is  placed  upon  the  back  with  a 
sandbag  underneath  the  neck  so  as  to  make  the  trachea  as  promi- 
nent as  possible.  An  incision  is  made  in  the  midline,  the  mus- 
cles separated,  the  trachea  exposed,  incised,  and  a  tracheotomy 
tube  introduced.  These  tracheotomy  tubes  are  of  various  types, 
but  the  one  generally  used  is  similar  to  Fig.  16.  It  is  very 
important,  after  the  tube  has  been  introduced,  to  see  that  it  is 
patent,  and  that  respiration  is  taking  place  freely.  As  a  pre- 
caution, tape  is  usually  threaded  through  the  tube  so  that  it 
will  not  slip  down  the  larynx  in  any  disorder  which  might 
ensue.  Inasmuch  as  the  outer  tube  comes  into  direct  contact 
with  the  skin,  it  is  a  good  plan  to  have  a  fine  layer  of  gauze 
covered  wdth  boric  ointment  inserted  between  the  tube  and  skin. 

Post-operative  Treatment. — The  tracheotomy  tube  is  a  new 
passage  through  which  air  is  drawn  into  the  lungs,  and  since 
the  air  is  no  longer  brought  through  the  normal  channels,  it  is 


NURSING  OF  THE  RESPIRATORY  SYSTEM  123 

important  that  above  all  the  tube  should  be  kept  patent  and 
clean.  In  order  to  ensure  perfect  cleanliness  and  free  respira- 
tion through  the  tube,  nurses  must  be  on  duty  day  and  night 
ever  alert  to  see  that  the  patient  has  plenty  of  air.  The  inner 
tube  should  be  removed  about  two  or  three  times  a  day,  cleansed, 
sterilized,  and  gently  reinserted.  It  should  never  be  cleaned  in 
situ,  i.  e.,  as  it  rests  in  the  patient's  trachea.  If  at  any  time 
the  tube  should  become  suddenly  plugged,  the  inner  tube  must 
be  withdravt^n  immediately.  At  times  the  patient  is  apt  to  cough, 
and  the  mucus  which  makes  its  appearance 
at  the  orifice  of  the  tube  should  be  wiped  /     . 

away    very    gently.       Occasionally    from  .-l^r^v.-''-fl 

coughing  violently  both  the  inner  and  outer  vC^Jl 

tubes  may  be  expelled,  and  for  this  reason  /S^^T"  ^ 

it  is  always  important  to  keep  a  trache-  X   /    i 

otomy  dilator  on  hand  to  meet  this  im-    ft^y^        e 
portant  emergency.     This  instrument  will   ^-^ 
keep  this  passage  open  until  another  tube  y 

may  be  obtained  and  inserted.  -p^^^    26. Tracheot- 

Another  important  thing  in  these  cases  omt  Tube.  A,  outer 
.      ,  1         ,1     .    .1  •         1  •  1     •  tube;    B,    inner    remov- 

is  to  remember  that  the  air  which  is  now  ^^^^q    tube-     C,    safety 

inspired  no   longer  has  the   advantage   of  ^ard ;  D,  catch  to  hold 

inner  tube  m  place;  E, 
'  being  warmed  and  freed  from  dust  by  the  slot  through  which  tape 

nasal  passages.  For  this  reason  in  the  -J^./yi^.^^^^fj^^^^ 
beginning,  thin  layers  of  gauze  which  have 

been  wrung  out  in  warm  water  should  be  placed  over  the  trache- 
otomy orifice  and  changed  every  half  hour.  Some  surgeons 
keep  the  patient  under  a  croup  tent  so  that  the  air  may  be 
warmed  by  the  steam  and  the  respiratory  tract  have  the  advan- 
tage of  a  warmed  air.  Compound  tincture  of  benzoin  may  be 
added  to  the  croup  kettles. 

There  are  very  few  conditions  which  require  more  conscien- 
tious nursing  than  do  these  patients,  because  their  life  is  abso- 
lutely dependent  upon  the  uninterrupted  inflow  and  outflow 
of  air  through  the  tube.  They  should  never  be  left  alone,  for 
one  never  knows  at  what  moment  the  tube  may  become  plugged 
and  the  patient  become  suddenly  asphyxiated.  Occasionally 
mucus  may  collect  in  the  trachea  and  not  be  expelled  through 


124  TEXTBOOK   OF  SURGICAL  NURSING 

the  tube.  The  reason  for  this  is  that  the  cough  is  insufficient  in 
strength  to  expt'l  the  iiiiicous  \)\\\\x-  In  these  eoiulitioiis  a  steril- 
ized featlier  might  be  introduced  through  the  tube  and  the 
trachea  tickled,  so  as  to  incite  coughing.  The  time  for  the  per- 
manent renio\al  of  the  lubt'  is  i)urely  at  the  discretion  of  the 
surgeon.  Very  ol'icn  some  surgeons  will  remove  the  double  silver 
tuhe  and  replace  it  l)y  a  rubber  one.  tluMi  remove  the  rubber  one 
when  they  see  fit. 

New  Growths  of  the  Larynx. — The  larynx,  like  the  other 
organs  in  the  body,  may  be  the  seat  of  benign  or  malignant 
growths.  Probabl}'  the  most  common  of  the  benign  growths  is 
the  iiapilloma.  These  growths  may  be  removed  in  three  ways: 
through  the  larynx  with  the  aid  of  the  lar.yngeal  mirror ;  from 
without  by  performing  a  thyrotomy  (an  incision  through  the 
thyroid  cartilage  of  the  larynx),  or  through  a  Jackson  or 
Killian  larjmgoscope.  The  instruments  used  for  their  removal 
may  be  the  snare,  curette,  forceps  or  galvano-cautery. 

Malignant  Growths, — The  symptoms  of  a  cancer  infiltrating 
the  lar3'nx  may  be  A^ery  similar  to  those  produced  by  the  benign 
growths.  Hoarseness,  later  loss  of  voice,  respiratory  difficulty, 
and  pain  are  very  common.  Later  when  the  growth  extends  and 
ulceration  becomes  evident,  cough  and  pain  on  swallowing  may 
be  very  evident.  The  only  treatment  is  surgical.  Either  one- 
half  or  the  entire  larynx  may  be  removed. 

Laryngectomy. — As  the  name  implies  the  operation  is  one 
in  which  the  larynx  is  excised.  The  operation  itself  is  preceded 
by  a  tracheotomy.  This  may  be  done  as  a  preliminary  operation 
one  day,  the  remainder  of  the  operation  being  performed  at 
another  time,  or  the  entire  operation  may  be  done  at  once. 

Operation. — The  first  part  of  the  procedure  is  practically  the 
same  as  a  tracheotomy  except  that  the  trachea  is  blocked  by  the 
use  of  a  Hahns  canula.  This  is  done  to  prevent  the  blood  from 
the  laryngectomy  from  leaking  down  the  trachea  into  the  lungs. 
The  canula  is  simply  a  tracheotomy  tube  which  has  been  previ- 
ously boiled  and  to  which  is  attached  and  securely  fastened  a 
sponge  scpieezed  dry  and  dipped  in  a  ten  per  cent,  ether  solution 
of  iodoform.  The  sponge  has  been  previously  sterilized  by  soak- 
ing in  a  25  per  cent,  alcohol  solution  for  several  days.     The 


NURSINa  OF  THK  RI^:SIM  R  ATORY  SYSTEM       125 

tube  with  the  sixjji^'c  is  introduced  dry.  Al'lcj-  it  is  in  llic  trachea 
from  five  to  ten  minutes  there  is  usually  enough  moisture  gener- 
ated to  swell  the  sponge  and  block  off  the  larynx  above.  The 
technic  of  the  operation  is  unimportant.  The  Ilahns  eanula  is 
taken  out  after  eight  hours  and  the  tracheotomy  tul)e  introduced. 

Post-operative  Treatment. — Since  the  larynx  has  been  re- 
moved and  the  pharynx  has  just  been  sutured,  it  is  highly  impor- 
tant that  the  patient  be  fed  for  the  first  few  days  by  rectum. 
For  the  next  four  to  five  days  feedings  should  be  administered 
through  the  nose  by  catheter,  and  within  a  week  as  a  rule,  the 
patient  is  able  to  swallow.  Of  course,  in  the  beginning,  only 
soft  diet  should  be  allowed.  These  patients  are  very  much 
depressed  because  of  the  loss  of  voice,  but  they  soon  learn  to 
whisper   and  make   themselves  understood. 

Injuries  to  the  Thoracic  Wall. — Injuries  to  the  thoracic  wall 
may  be  the  result  of  bullets,  stab  wounds,  or  compound  fractures 
of  the  ribs.  The  latter  occur  quite  often  following  severe  com- 
pressions of  the  chest,  such  as  occur  in  "run-over"  accidents. 
Wounds  of  the  chest  may  be  superficial,  involving  skin  and 
muscle,  or  deep,  penetrating  the  pleural  cavity.  The  dangers 
of  the  last  named  variety  are  the  complications  of  pneumothorax 
(air  in  the  pleural  cavity  with  collapse  of  the  lung),  hemo- 
thorax, a  condition  in  which  the  pleural  cavity  is  filled  with  blood 
due  to  injury  of  the  blood  vessels  of  the  lung  itself;  or,  the 
possibility  of  a  superimposed  infection  of  the  pneumothorax 
( pyopneumothorax) . 

Treatment  of  Injuries  to  the  Thoracic  Wall. — This  is  usually 
surgical  in  nature.  The  wound  is  thoroughly  cleansed  and  the 
hemorrhage  controlled.  If  any  of  the  ribs  have  been  fractured, 
they  are  securely  strapped  and  the  patient  kept  in  bed  for  a  few 
days.  Many  of  these  cases,  especiallj^  those  with  deep,  penetrat- 
ing wounds,  develop  serious  complications,  such  as  pneumonia, 
or  infection  of 'the  pleural  cavity  (empyema). 

Empyema. — One  of  the  complications  that  may  occur  in  chest 
conditions  is  empyema,  an  infection  of  the  pleural  cavity.  This 
is  usually  the  result  of  a  pneumonia  and  rarely  occurs  as  a 
primary  condition. 

Symptoms. — The  patient  gives  a  previous  history  of  pneu- 


126  TEXTBOOK  OF  SURGICAL  NURSING 

nioiiia,  as  a  rule.  After  Ihc  piuMiiiKniiii  luis  rcsdlvcd,  or  even 
before  this  period,  a  siuldcii  rise  in  Iciiipcraliire  may  oeciir, 
aceompanied  by  fever,  cliills,  and  tlic  pl\ysieal  signs  of  Hnid  in 
the  pleural  cavity.  This  eollection  of  iiuid  or  pus  may  be 
general  in  nature,  or  localized  (sacculated).  As  pus  in  olliei- 
parts  of  the  body  usually  requires  drainage  as  soon  as  it  is 
formed,  here  also  an  attempt  should  be  made  to  remove  it. 

Treatment. — "While  it  was  customary  before  the  war  to  re- 
sect a  rib  and  insert  a  drainage  tube  into  tlie  pleural  cavity  as 
soon  as  a  diagnosis  of  empyema  was  made,  army  experience  has 
taught  that  such  radical  procedure  is  not  always  necessary. 
In  fact,  in  the  beginning,  it  is  better  to  draw  off  tlie  fluid  which 
has  accumulated  with  a  needle  and  syringe,  or  Potain  aspirator, 
thereby  relieving  the  patient,  and  at  the  same  time,  reducing 
certain  elements  which  might  lessen  the  shock  at  the  time  of  the 
future  operation.  It  is  also  true  that  some  of  the  patients 
recover  with  this  simple  aspiratory  procedure,  although  the  great 
majority  must  have  a  more  radical  operation  performed  sooner 
or  later.  The  more  radical  procedure  consists  in  the  partial 
excision  of  one  of  the  lower  ribs  so  that  better  and  more  adequate 
drainage  maj^  be  secured. 

Operative  Treatment. — Inasmuch  as  these  patients  are  in  a 
weakened  physical  condition  from  their  pneumonia,  or  from  the 
absorption  of  the  poisons  of  the  pus  in  the  pleural  cavity,  it  is 
advisable  not  to  administer  a  general  anesthetic,  but  to  employ 
local  anesthesia.    This  works  with  remarkable  success. 

Since  the  patients  feel  more  comfortable  when  sitting  almost 
upright,  the  operation  is  performed  in  this  position.  An  aspi- 
rating needle  with  syringe  locates  the  area  of  pus ;  its  location  is 
the  determining  factor  as  to  which  rib  is  to  be  partially  resected. 
In  general  empyema  or  suppurative  pleurisj^,  the  incision  is 
generally  made  along  the  eighth  or  ninth  ribs.  A  part  of  the 
rib  is  removed  subperiosteally,  exposing  the  periosteum  beneath 
which  is  the  outer  surface  of  the  pleura.  The  pleura  is  then 
opened  by  incision  and  the  pus  allowed  to  gradually  escape. 
A  drainage  tube  is  then  placed  into  the  pleural  cavity. 

There  are  many  ways  of  draining  the  thoracic  cavity.  Some 
employ  a  Brewer  tube  (Fig.  17)  ;  others  a  simple  rubber  drain- 


NURSING  OF  THE  RESPIRATORY  SYSTEM        127 


age  tube.  In  empyema  cases,  great  care  should  be  taken  that  the 
number  of  drainage  tubes  used  be  carefully  noted  and  recorded. 
The  pleural  cavity  is  a  notorious  hiding  place  for  them,  and 
very  often  a  lost  tube  is  the  reason  for  a  persistent  sinus  con- 
tinually discharging  large  quantities  of  pus. 

After    Treatment. — Inasmuch    as    the    discharge    from    the 
pleural  cavity  is  moderately  free,  very  often  the  drainage  tubes 
are    connected    with    bottle    drainage.      Occasionally,    when    a 
Brewer  tube  is  employed,  a  piece  of  rubber 
dam  is  snugly  fitted  around  the  free  end  of 
the  drainage  tube,  and  the  open  end  of  the 
dam  is  placed  in  a  bottle  under  a  water  level 
so  that  while  the  pleural  fluid  may  escape 
from  the  chest  no  air  can  enter  the  pleural 
cavity.     The  result  of  this  is  that  a  negative 
pressure  is  soon  established,  the  lungs  expand 
earlier,    and    the    patient's    convalescence   is 
shortened. 

The  discharge  is  rather  copious  for  the  first 
few  days  and  superficial  dressings  must  be 
changed  and  reinforced  whenever  necessary. 
After  a  few  days  the  tubes  within  the  chest 
are  gradually  shortened,  and  as  soon  as  the 
discharge  is  very  thin  and  the  temperature 
is  normal,  the  tubes  may  be  withdrawn  alto- 
gether. While  the  patients  are  in  bed,  they 
should  be  encouraged  to  breathe  as  deeply  as 
possible  so  as  to  aid  the  expansion  of  the  collapsed  lung.  With 
this  end  in  view,  they  should  blow  fluids  from  one  bottle  into 
another,  and  children  should  be  given  those  toys  which  encourage 
blowing,  such  as  horns  or  balloons.  If  the  temperature  suddenly 
rises  after  the  drainage  has  been  removed,  it  simply  means  a 
reaccumulation  of  fluid  in  the  pleural  cavity,  and  necessitates 
an  immediate  reinsertion  of  the  tube. 

These  patients  should  be  allowed  out  of  bed  as  soon  as  possible, 
and  wheeled  into  the  open  air.  If  the  weather  is  clear,  their  beds 
might  even  be  moved  into  the  open.    The  diet  should  be  high  in 


,   C 


Fig.  17. — Brew- 
er Empyema  Tube. 
A,  Rubber  Disc 
resting  tightly 
against  parietal 
pleura;  B,  rubber 
disc  resting  tightly 
against  skin ;  C, 
rubber  tube  con- 
nected to  bottle 
drainage. 


128  TEXTBOOK  OF  SURGICAL  NURSING 

carbohydrates,  and  tonics  should  be  given  to  restore  their  lost 
strength. 

The  Lungs. — The  surgery  of  the  lungs  is  still  in  its  early 
stages  of  development,  and  the  operations  done  upon  these 
essential  organs  of  respiration  are  but  few  in  number.  This  is 
due  to  the  mechanical  difficulty  of  apjiroach  and  exposure 
through  the  thoracic  wall,  and  because  of  the  difficulty  of  main- 
taining the  potential  negative  pressure  during  an  operation. 
The  latter  normally  exists  between  the  parietal  pleura  lining 
the  interior  of  the  thoracic  wall  and  the  visceral  pleura  which 
covers  the  lungs  themselves.  In  the  various  phases  of  respira- 
tion, the  parietal  and  visceral  pleurte  are  continually  in  con- 
tact; but  should,  for  some  reason,  the  air  from  the  outer  world 
enter  this  space,  either  by  rupture  of  the  lung  tissue  itself  or 
through  the  thoracic  wall,  the  negative  pressure  will  be  destroyed 
and  the  lung  will  collapse.  A  large  space  filled  with  air  will  thus 
be  left  between  the  parietal  and  visceral  pleura.  If  this  is  remem- 
bered it  will  not  seem  strange  that  pleural  and  lung  conditions 
take  such  long  periods  of  time  to  return  to  normal  after  opera- 
tion, for  the  infection  of  this  large  rigid  cavity  must  be  sterilized, 
the  air  within  the  chest  absorbed,  and  the  lung  permitted  to 
expand  with  the  reestablishment  of  the  negative  pressure. 

Operations  upon  the  Lungs. — There  are  several  indications 
in  surgery  for  operations  upon  the  lungs  themselves.  Occasion- 
ally, it  is  advisable  to  remove  a  lobe  of  the  lung  because  of  some 
extensive  infective  condition,  such  as  an  abscess.  As  already 
mentioned,  the  normal  thoracic  cavity  is  under  negative  pressure, 
and  when  an  opening  is  made  communicating  the  pleural  cavity 
with  the  external  world,  this  negative  pressure  is  destroyed,  the 
lung  collapses  and  expansion  is  impossible.  There  are  two 
methods  which  aim  to  overcome  the  collapse  of  the  lung.  One 
is  to  do  the  operation  in  a  chamber  which  is  under  negative  pres- 
sure so  that  there  is  practically  no  difference  between  the  nega- 
tive pressure  in  the  pleural  cavity  and  the  negative  pressure  in 
the  room.  By  the  other  method,  the  air  is  under  increased 
pressure  and  is  introduced  within  the  lung  so  that  the  lung  is 
kept  expanded  even  though  the  negative  pressure  within  the 
thorax  is  destroyed. 


NURSING  OF  THE  RESPIRATORY  SYSTEM       129 

Methods  for  Maintaining  Negative  Pressure. — This  may  be 
accomplished  by  two  main  methods.  The  operation  may  be 
performed  in  a  special  negative  pressure  chamber.  The  rooms 
were  designed  by  Sauerbruch,  and  are  portable.  By  the  other 
method,  the  ordinary  operating  room  is  converted  into  a  nega- 
tive pressure  chamber,  the  patient's  head  being  passed  through 
an  opening  in  the  wall,  so  that  it  is  under  positive  pressure,  while 
the  thorax  and  the  rest  of  the  body  within  the  room  itself  are 
under  the  negative.  The  negative  pressure  used  is  from  eight 
to  ten  millimeters  of  mercury. 

Positive  Pressure  Method. — This  method  consists  in  keeping 
the  lungs  expanded  by  forcing  air  under  pressure  into  them 
through  the  trachea.  A  catheter  is  passed  through  the  mouth 
into  the  trachea  and  a  stream  of  warm  air  under  pressure  mixed 
with  vaporized  ether  is  forced  through  by  means  of  a  pump. 
This  is  successful,  and  does  not  require  as  much  time  or  prepara- 
tion as  the  negative  pressure  variety  of  operations. 

Foreign  Bodies  in  the  Lungs. — Very  often  foreign  bodies  be- 
come lodged  in  the  lungs,  if  they  pass  the  trachea  and  bronchi 
without  being  obstructed ;  they  may  be  localized  by  means  of  the 
X-ray  if  the  body  is  opaque,  or  with  the  bronchoscope,  an  instru- 
ment for  looking  directly  into  the  bronchi.  Quite  often  they 
may  be  removed  through  these  instruments  or,  in  very  rare 
instances,  the  lung  may  be  incised  to  remove  the  foreign  bodies. 

Pulmonary  Tuberculosis. — While  this  does  not  come  under 
the  general  surgical  field,  still  the  surgeon  very  often  is  called 
upon  to  inject  air  into  the  pleural  cavity  to  cause  the  collapse 
of  the  lung.  The  purpose  is  to  give  the  lung  a  rest  by  collapsing 
it  with  the  hope  that  the  increased  circulation  may  conquer  the 
tubercular  infection.  The  gas,  which  is  purified  nitrogen,  is 
introduced  by  means  of  a  needle. 


CHAPTER  X 

THE    SURGERY   AND    SURGICAL   NURSING   OF    THE    SKIN   AND 

APPENDAGES 

Surgical  Conditions  Involving-  the  Skin. — A  wound  may  be 
defined  as  a  discontinuity  of  tissue.  It  may  be  superficial  or 
deep,  clean  or  contaminated,  accidental  or  intentional.  For 
purposes  of  classification,  wounds  may  be  divided  into  abra- 
sions, contusions,  punctures  and  lacerations.  When  the  surface 
layers  of  the  epithelium  are  scraped  away,  the  wound  is  spoken 
of  as  an  abrasion;  when  they  have  been  destroyed  by  some 
pressure,  but  yet  not  actually  removed,  a  contusion  results;  a 
punctured  wound  is  the  type  left  by  a  nail  or  awl ;  a  laceration 
is  caused  by  the  deeper  layers  of  the  skin  together  with  the 
epithelium  being  torn.  All  these  wounds  may  be  clean  or  in- 
fected. If  they  are  clean  they  will  heal  in  the  manner  de- 
scribed in  Chapter  II.  If  they  are  infected  by  bacteria,  the 
various  sequellae  which  have  been  already  outlined  may  ensue. 

Treatment. — Hemorrhage  should  be  arrested  first;  then  any 
foreign  material  which  may  be  present  is  removed,  and  the 
wound  sterilized  and  protected  from  any  further  contamination 
by  a  dressing  and  bandage. 

In  most  wounds,  hemorrhage  may  be  arrested  by  simple 
pressure,  provided  that  no  deep  blood  vessels  are  cut.  This 
pressure  should  be  applied  directly  over  the  bleeding  surface, 
the  material  used  being  any  sterile  gauze,  or  in  emergencies,  a 
freshly  laundered  handkerchief.  Should  the  bleeding  still  be 
profuse  the  measures  outlined  in  Chapter  III  may  be  tried. 
After  the  bleeding  has  been  controlled,  the  wound  should  be 
cleansed  by  simple  irrigation  with  sterile  water  or  a  weak 
solution  of  iodine. 

Antiseptics. — The  application  of  iodine  to  a  bleeding  sur^ 
face  is  of  little  avail,  for  it  has  been  definitely  proven  that 
iodine  here  has  little  or  no  effect.     Tincture  of  iodine  on  a  dry 

130 


NURSING  OP  THE  SKIN  AND  APPENDAGES     131 

surface  is  indeed  efficacious  and  all  lacerations,  even  though 
the  infection  be  doubtful,  should  be  thoroughly  iodinized.  In 
the  application  of  iodine  to  abrasions,  it  must  be  remembered 
that  if  more  than  one  coat  is  given,  it  is  very  apt  to  burn  the 
skin.  Thoughtless  painting  and  repainting  of  small  abrasions 
occurring  in  the  tender  skin  of  children  or  women  may  result 
in  a  burn  which  is  much  worse  than  the  original  injury.  Some 
surgeons  prefer  to  use  peroxide  of  hydrogen.  All  wounds  which 
have  come  into  contact  with  manure  and  dirt  should  be  cleansed 
first  with  peroxide  of  hydrogen  and  then  iodinized.  Of  course, 
the  number  of  antiseptics  used  are  many,  but  experience  has 
shown  that  while  some  antiseptics  certainly  kill  bacteria,  they 
may  destroy  the  tissues  themselves,  and  occasionally  poison  the 
individual.  Because  of  this,  bichloride  of  mercury  and  carbolic 
acid  have  fallen  into  disrepute.  They  possess  extremely  irri- 
tating properties  and  there  is  always  danger  entailed  in  their 
use.  The  popular  antiseptic  at  present  is  one  which  has  been 
developed  during  the  war  and  w^hich  has  had  such  wonderful 
success  in  the  sterilization  of  wounds.  It  is  the  Dakin  solution 
and  a  complete  discussion  of  it  will  be  found  in  Chapter  XIX. 

After  tlie  bleeding  has  been  stopped,  and  sterilization  has 
taken  place,  the  wound  should  be  protected  from  foreign  ma- 
terials such  as  dirt  or  bacteria.  Sterile  gauze  is  applied,  either 
dry  or  greased  with  some  sterile  ointment  (boric  acid,  vaseline, 
or  liquid  albolene),  to  prevent  it  from  sticking  to  the  wound. 
The  dressing  may  be  held  in  place  by  strips  of  adhesive  plaster 
or  a  bandage,  whichever  suits  the  location  of  the  injury  the  best. 
All  dressings  should  be  made  as  small  and  inconspicuous  as 
possible  both  for  cosmetic  effect  and  reasons  of  economy. 

Lacerated  Wounds. — Wounds  which  gape  considerably  are 
sutured  because  the  period  of  healing  and  the  amount  of  scar 
tissue  are  thus  lessened.  The  material  used  for  the  suture  of 
wounds  may  be  horsehair,  silk,  silkworm  gut,  plain,  or  chromic 
catgut  described  in  detail  in  Chapter  XV.  For  wounds  of  the 
face,  horsehair  is  the  material  of  choice  on  account  of  its  fine  tex- 
ture. For  deeper  wounds,  material  possessing  a  greater  strength, 
either  silk  or  silkworm  gut,  is  used.  The  needles  employed  are 
full  curved,  or  straight,  small  Hagedorn  type.     Care  should  al- 


182  TEXTBOOK  OP  SURGICAL  NURSING 

■ways  1)0  taken  flial  llie  eye  o\'  llic  lu'ctllc  is  patent  and  the  cutting 
edge  keen  and  sli;irp.  Needle  holders  should  always  accompany 
needles.  ,  The  type  of  holder  depends  upon  the  idiosyncrasy  of 
the  surgeon.  To  summarize  then :  The  arrest  of  hemorrhage, 
the  cleansing  and  sterilization  of  the  wound  and  its  protection 
from  infection  are  the  essentials  in  the  minor  surgical  proce- 
dures involving  the  skin  and  deeper  tissues.  Nurses  are  always 
expected  to  have  those  things  prepared  which  are  necessary  for 
the  fulfillment  of  these  essentials. 

Infected  Wounds. — If  a  wound  is  infected,  the  aim  of  the 
surgeon  is  to  liberate  the  pus,  establish  its  free  drainage,  steril- 
ize the  wound  and  convert  an  infected  into  a  clean  one.  To 
obtain  free  drainage,  an  incision  is  made,  or  in  a  recently  sutured 
wound,  a  few  sutures  are  removed,  and  to  aid  the  free  escape 
of  pus,  a  drain  is  inserted.  In  small  infections  the  incision  is 
done  under  local  anesthesia  with  a  knife  (scalpel).  Knives 
should  always  be  sharp  and  keen  as  razors.  Drains  are  the 
handiwork  of  a  nurse  and  their  manufacture  should  be  clearly 
and  thoroughly  understood.  The  types  of  drains  and  their 
method  of  preparation  are  described  in  detail  on  pages  310-311, 
Chapter  XVII.  AVhile  the  drainage  secures  the  escape  of  pus,  its 
freer  exit  is  promoted  by  the  use  of  wet  dressings  or  dry  heat. 

Wet  Dressings. — The  means  of  keeping  dressings  wet  are 
many.  The  dressing  may  be  wetted  and  then  covered  with  oil 
skin  or  rubber  tissue  to  prevent  evaporation ;  or  a  sterile  solu- 
tion may  be  poured  upon  the  wound  through  the  dressing  every 
so  often ;  or  the  dressing  may  be  kept  continually  moistened 
by  a  warm  saline  drip  or  continuous  immersion  in  a  water  bath. 
Infected  wounds  which  are  treated  with  Dakin's  solution  re- 
quire special  technic  (see  Chapter  XIX).  In  all  wet  dressings 
the  nurse  should  take  particular  care  that  the  fluid  is  applied 
to  the  wound  and  the  wound  only,  and  that  the  surrounding 
skin  does  not  become  macerated  or  injured. 

Suction  Drainage. — Very  often  to  secure  better  drainage, 
gentle  suction  may  be  applied  to  the  end  of  the  tube,  using  either 
the  water  siphon  method  or  the  suction  machine. 

Siphon  Drainage. — One  end  of  a  Y-tube  is  attached  to  the 
drainage  tube  and  another  to  the  moving  column  of  water  from 


NURSING  OF  THE  SKIN  AND  APPENDAGES    133 

an  elevated  tank  or  a  faucet.  This  is  arranged  sa  that  the 
flowing  water  will  exert  suction  and  carry  off  with  it  drainage. 
The  disadvantage  in  case  a  tank  is  employed  is  that  water  must 
be  continually  supplied  to  keep  up  the  siphonage. 

Dry  Heat. — Some  surgeons,  instead  of  using  moist  applica- 
tions, prefer  the  use  of  dry  heat.  It  should  be  remembered  that 
in  extensive  wounds  the  nerves  are  often  destroyed  and  sensa- 
tion is  lost,  so  that  all  warm  applications  should  be  tested  first 
by  the  hand  of  the  nurse  before  the  heat  is  applied,  for  a  bum  in- 
flicted on  any  patient  is  unpardonable.  Heat  may  be  applied 
by  hot  water  bottles,  hot  poultices,  the  electric  coil  or  electric 
pad.  These  may  be  applied  intermittently  or  continuously.  For 
the  continuous  application  the  best  form  is  the  electric  coil,  as 
the  degree  of  heat  may  be  regulated  and  kept  fairly  constant. 
Baking  a  suppurating  wound  is  also  occasionally  employed  and 
at  times  found  very  helpful.  Probably  there  is  nothing  which 
gives  so  much  relief  as  poultices,  because  they  are  light  in  weight 
and  are  easily  adaptable  to  the  region  required.  The  most 
common  poulticing  material  is  flaxseed,  although  there  are  many 
proprietary  compounds  which  are  equally  good  and  less  trouble- 
some. Inasmuch  as  poultices  are  very  apt  to  lose  heat  rather 
rapidly,  the  electric  coil  or  a  hot  water  bottle  should  be  super- 
imposed. Mustard  plasters  are  rarely  used  in  surgical  nursing, 
because  if  improperly  applied,  they  burn  the  skin,  and  they  can- 
not be  used  continuously. 

Packing. — When  the  cavity  is  rather  large,  and  when  heal- 
ing must  take  place  by  granulating  from  the  bottom,  the  wound 
must  be  packed.  Packing  a  wound  is  also  an  aid  to  drainage. 
The  materials  used  must  be  sterile,  absorbent,  soft  and  of  such 
nature  that  they  will  not  shed  their  threads  nor  flood  the  wound 
with  foreign  bodies.  It  is  of  prime  importance  that  the  nurse 
carefully  observe  the  packing  of  wounds,  noting  particularly 
the  number  of  pieces  inserted  into  the  cavity.  Most  packing 
requires  changing  in  from  twenty-four  to  forty-eight  hours  be- 
cause it  becomes  foul-smelling  and  acts  as  a  dam  rather  than  a 
drain.  The  width  of  the  packing  is  dependent  upon  the  depth 
and  diameter  of  the  wound;  and  whether  it  should  be  plain, 


134'  TEXTBOOK  OF  SURGICAL  NURSING 

or  medicated  with  iodoform  or  bismuth  is  a  question  decided  by 
the  surgeon. 

Treatment  of  Healing  Wounds. — AVhen  the  discharge  and 
induration  of  an  infected  wound  becomes  less,  the  surgeon  will 
begin  reducing  or  removing  the  drainage,  and  will  apply  medi- 
cations to  stimulate  granulation  tissue.  Granulation  tissue  may 
be  stimulated  chemically  or  physically.  Weak  solutions  of  silver 
nitrate  or  the  actual  caustic  stick  are  sometimes  used;  balsam 
of  Peru  is  very  valuable.  The  size  of  the  wound  may  be  reduced 
by  drawing  the  adjacent  edges  together  with  adhesive  plaster; 
and,  at  times,  strapping  the  granulating  areas  with  sterile  adhe- 
sive plaster  will  stimulate  the  granulations  and  also  the  surface 
epithelium  to  growth. 

Secondary  Suture. — Since  the  absolute  sterilization  of  in- 
fected wounds  by  the  Dakin  method  is  possible,  secondary  suture 
of  granulating  wounds  is  done  very  often  and  has  proven  quite 
successful  (see  Chapter  XIX).  As  soon  as  the  wound  has  be- 
come filled  with  granulation  tissue,  the  surface  epithelium,  or  the 
skin  itself  begins  to  grow.  If  the  area  to  be  covered  by  skin  is 
too  great,  and  the  resulting  scar  would  be  too  big,  a  graft  of  skin 
may  be  resorted  to. 

Skin-Grafts. — Skin-grafts  are  of  three  varieties, — Thiersch, 
Reverdin,  and  Wolf. 

Thiersch  Graft. — The  superficial  layers  of  the  epithelium  are 
shaved  off  with  a  razor  and  planted  over  the  wound,  the  grafts 
being  rather  large  in  size. 

Reverdin  Graft. — In  this  type  small  thin  portions  of  the  su- 
perficial layer  of  the  skin  are  snipped  off  with  scissors,  and 
placed  upon  the  granulating  wound. 

Wolf  Graft. — In  this  variety,  the  entire  thickness  of  the  skin 
is  utilized  as  a  graft,  or  it  remains  connected  by  a  pedicle  to 
that  part  of  the  body  from  which  it  was  taken,  and  after  the 
graft  is  firmly  attached  the  pedicle  is  severed. 

In  all  skin-grafts,  the  nurse  must  not  forget  to  keep  the  part 
quiet  and  warm.  In  removing  dressings,  the  utmost  care  should 
be  observed  for  fear  of  disturbing  the  graft  itself,  and  as  in  all 
surgical  procedures,  the  best  aseptic  technic  should  be  main- 
tained. 


NURSING  OF  THE  SKIN  AND  APPENDAGES    135 

Burns. — While  a  French  surgeon  originally  divided  burns 
into  six  degrees  or  stages,  according  to  the  depth  to  which  the 
injury  penetrated,  it  will  really  suffice  for  nursing  purposes  to 
divide  them  into  three.  The  agents  which  produce  bums  are 
many.  Heat  in  the  form  of  solids,  liquids,  or  steam ;  chemicals, 
such  as  strong  acids, — for  example,  carbolic,  acetic,  hydro- 
chloric; powerful  alkalis,  such  as  sodium  hydroxide,  chloride 
of  lime;  special  agents,  such  as  X-ray,  electrical  currents  and 
radium  when  not  properly  used  may  all  cause  very  severe  burns. 
Closely  allied  to  those  bums  caused  by  heat  are  those  due  to 
the  action  of  cold  either  from  exposure  to  low  temperatures, 
such  as  frostbite,  or  those  resulting  from  actual  contact  with 
sold  substances  in  the  form  of  ice,  snow,  or  liquid  air. 

The  pathology  and  clinical  appearance  of  all  burns  are  es- 
sentially the  same  regardless  of  the  agent  inflicting  the  injury, 
but  the  degree  varies.  First  degree  burns  are  recognized  as 
those  in  which  there  is  redness,  with  some  pain  and  swelling, 
followed  by  a  scaling  of  the  skin.  If  the  redness  is  of  a  greater 
degree,  blisters  appear ;  this  is  a  second  degree  burn.  All  other 
bums  might  be  classified  as  third  degree.  They  vary  from 
definite  charred  areas  to  those  cases  in  which  an  entire  limb 
or  more  is  involved.  The  symptoms  which  result  may  be  classi- 
fied as  local  and  constitutional. 

Local  Symptoms. — There  is  a  marked  inflammatory  reaction 
of  the'  parts  adjacent  to  the  bum  followed  soon  by  sloughing 
of  the  charred  or  injured  tissues  and,  finally,  after  the  wound  has 
been  cleansed  and  the  granulations  are  vigorous,  healing  ensues. 

During  the  first  and  second  periods,  there  is  considerable  ab- 
sorption from  the  products  of  destroyed  tissue  and  the  patient 
may  suffer  from  certain  constitutional  complications ;  these  may 
be  very  mild  or  so  severe  as  to  cause  death.  The  causes  of 
death  following  burns  may  be  shock,  poisoning  from  the  charred 
tissues,  or  complications  arising  from  infectious  such  as  ery- 
sipelas or  sepsis.  It  should  be  remembered  that  extensive  bums 
rather  than  limited  deep  ones  are  the  more  serious,  and  that 
children  with  skin  burns  averaging  more  than  one-third  of  their 
body  are  apt  to  die  from  the  effects. 


136  TEXTBOOK  OF  SURGICAL  NURSING 

Treatment. — Tlie  treatment  of  burns  may  be  grouped  under 

two  heads, — local  and  j^'oneral. 

General  Treatment. — In  extensive  burns  there  is  often  deep 
shock  Avliieh  should  be  treated  immediately.  The  patient  should 
be  ]ilaced  in  the  shock  position.  The  body  must  be  kept  warm 
with  hot  water  bottles  and  blankets.  Fluid  should  be  given 
either  by  rectum  in  the  form  of  a  IMurphy  drip,  or  in  very  severe 
depressed  conditions,  a  saline  infusion.  If  the  pain  is  intense, 
morphia  may  be  riM|nired.  Tt  oecasionall.y  liappens  that,  to- 
gether with  the  burns,  the  patient  suffers  from  poisoning  of 
carbon  monoxide  gas. 

Carbon  Monoxide  Poisoning. — Tliis  is  recognized  by  the 
great  difficidty  with  which  these  patients  breathe,  the  fact  that 
their  lips  are  a  very  deep  red  and  their  skin  a  bluish  hue.  The 
condition  requires  urgent  interference. 

Treatment. — The  blood  must  be  rid  of  the  excess  carbon 
monoxide  and  its  oxygen  content  increased.  The  patient  may 
be  given  oxygen  from  a  commercial  oxygen  tank  by  means  of 
a  funnel  held  directly  over  the  nose  and  mouth.  To  prevent 
further  loss  of  oxj^gen,  a  paper  cornucopia  may  be  fastened  to 
the  funnel.  If  the  congestion  of  the  patient  is  very  extreme, 
blood  may  be  removed  from  a  vein  in  the  arm.  This  reduces 
the  actual  blood  content  of  carbon  monoxide,  and  then  the  pa- 
tient may  be  given  an  infusion  of  saline  or  a  transfusion  of 
blood  which  will  still  further  decrease  the  amount  of  poisonous 
gas. 

Local  Treatment. — First  Degree  : — If  there  is  much  smarting 
and  pain,  a  paste  of  bicarbonate  of  soda,  or  cold  cream,  may  be 
applied,  and  the  burned  area  protected  from  the  air. 

Second  Degree : — When  blisters  or  blebs  are  present,  they 
should  be  opened  by  puncture  with  a  sterile  needle  and  the  serum 
removed.  After  this,  sterile  vaseline  or  boric  ointment  may  be 
applied. 

Third  Degree: — If  the  patient  has  rather  extensive  burns, 
and  the  clothes  covering  the  skin  have  been  destroyed  by  fire,  to 
prevent  greater  shock,  it  is  better  to  give  the  patient  anesthesia, 
remove  the  clothes,  cleanse  the  burned  areas  very  thoroughly 
with  either  copious  washings  of  sterile  saline,  or  bichloride  in 


NURSING  OF  THE  SKIN  AND  APPENDAGES     137 

one  to  one  thousand  solution,  followed  by  saline  irrigations. 
Wet  dressings  of  boric  acid  or  sublimate  in  one  to  ten  thousand 
solution  may  be  used.  These  (may  remain  undisturbed  for 
forty-eight  hours,  if  the  patient  is  moderately  comfortable. 

Some  use  sterile  boric  acid  dressings  and  within  recent  years, 
picric  acid  in  a  saturated  watery  solution  has  gained  favor. 
After  the  first  two  days,  it  is  advisable  to  dress  the  cases  daily, 
and  as  soon  as  the  sloughs  have  disappeared,  and  granulations 
appear,  the  wounds  may  be  treated  as  any  healing  type.  When 
there  has  been  extreme  loss  of  epithelium  the  denuded  areas  may 
be  supplied  with  skin-grafts. 

While  some  surgeons  prefer  wet  dressings  and  some  oint- 
ments, still  others  apply  nothing,  leaving  the  burn  exposed  to 
the  open  air.  The  burned  area  is  protected  from  the  bed  linens 
by  a  cradle  and  the  part  exposed  to  sunlight  for  varying  periods 
of  each  day.  The  air  has  a  tendency  to  dry  the  part  and  later 
the  granulations  may  be  stimulated  by  the  actinic  rays  of  the 
sun.  Then  when  all  the  sloughs  have  separated  and  the  wound 
is  filled  with  good  red  granulations,  it  may  be  strapped  by  the 
application  of  sterile  adhesive  over  the  granulations  to  stimu- 
late the  surface  epithelium  ;•  or  the  wound  may  be  skin-grafted. 
After  the  wound  has  healed  the  later  contractions  of  the  scar 
tissue  may  result  in  a  diminution  of  the  normal  function  of  the 
part ;  so  early  passive,  and  later  active  motion  with  massage 
should  be  given. 

Paraffin  Treatment  of  Burns. — During  the  Great  War  com- 
batant troops  were  exposed  to  the  terrors  of  gas  attacks  and  the 
chlorine  and  mustard  gas  left  their  marks  by  horrible  burns 
of  a  superficial  and  deep  nature.  The  areas  were  treated  by 
paraffin  or  a  proprietary  substance  called  ambrine.  Ambrine  is 
applied  by  a  special  apparatus  which  sprays  the  warm  wax  over 
the  wound  in  a  fine  layer.  The  method  is  somewhat  as  follows: 
— The  part  is  thoroughly  cleansed,  dried,  and  wrapped  with  a 
sterile  towel.  The  ambrine  is  melted  by  the  heat  of  either  an 
alcohol  lamp  or  Bunsen  burner  to  a  temperature  of  50°  C.  In 
the  meantime  the  water  bath  for  the  actual  liquefied  ambrine 
is  filled  with  boiling  water.  The  ambrine  is  poured  into  the 
container,  the  container  telescoped  into  the  water  bath  and  the 


138  TEXTBOOK  OF  SURGICAL  NURSING 

atomizing  arrangement  is  screwed  over  both.  Then  by  air  pres- 
sure the  liquefied  wax  is  sprayed  over  the  part  in  a  delicate, 
thin,  even,  film,  and  tlie  part  covered  with  a  fine  cotton  batting, 
and  a  bandage  applied.  The  advantages  of  this  method  are 
painlessness  of  application,  absolute  sterility,  formation  of  a 
soft  splint-like  dressing  over  the  wounded  area  rendering  it 
immobile  and  thereby  diminishing  pain.  At  the  end  of  twenty- 
four  hours  due  to  the  exuding  serum,  the  wax  layer  with  the 
thin  cotton  batting  attached  separates  rather  easily  and  pain- 
lessly. AVhile  this  method  requires  much  time  and  patience, 
the  end  results  easily  compensate  for  the  trouble  involved. 

It  should  always  be  remembered  that  the  burned  areas  are 
portals  of  entry  for  the  various  pathological  bacteria.  Exces- 
sive care  should  therefore  be  taken  to  guard  against  infection. 
The  application  of  unsterile  home  remedies,  such  as  flour  and 
water,  olive  oil,  etc.,  is  to  be  condemned.  If  a  first  aid  dressing 
must  be  applied  and  there  are  no  sterile  supplies  at  hand  it  is 
better  to  cover  the  part  with  a  freshly  laundered,  clean,  dry 
towel  until  the  proper  material  may  be  obtained. 

The  Breast. — Diseases  of  the  breast  form  a  relatively  im- 
portant chapter  in  surgery.  In  the  main  they  are  of  two  great 
varieties, — those  due  to  inflammation  and  those  due  to  new 
growth.  Inflammation  may  involve  either  the  nipples  or  the 
breast  and  may  be  acute  or  chronic. 

The  Nipples. — Cracked  or  fissured  nipples,  often  seen  dur- 
ing lactation,  are  especially  painful  because  the  skin  has  become 
broken.  They  may  fonn  a  portal  of  entry  for  the  various 
microorganisms  and  thus  give  rise  to  infections  of  the  breast 
itself,  or,  when  the  child  suckles,  it  may  swallow  some  of  the 
diseased  tissues  about  the  cracked  nipples. 

Treatment. — All  nipples  after  nursing  should  be  thoroughly 
but  gentl}'  washed  with  boric  acid,  then  dried  and  powdered 
with  borated  talcum.  If  fissures  are  present  the  child  may  nurse 
through  a  nipple  shield,  and  in  the  interval  the  nipples  may  be 
treated  with  boroglyceride,  touched  with  silver  nitrate  (solid) 
or  painted  gently  with  tannic  acid.  These  measures  suffice, 
as  a  rule,  to  bring  the  nipple  back  to  its  normal  healthy  status. 

Acute  Mastitis. — Acute  inflammations  of  the  breast,  known 


NURSING  OF  THE  SKIN  AND  APPENDAGES    139 

as  acute  mastitis,  usually  occur  in  women  during  the  close  of 
the  lactating  period.  It  is  the  result  of  improper  hygiene  of 
the  nipples,  although  this  may  not  always  be  the  case. 

Symptoms. — The  patient  may  complain  of  pain  and  heavy 
feeling  in  the  breast,  and,  at  the  same  time,  redness,  swelling, 
and  areas  of  hardness  may  appear  in  certain  parts  of  the  breast. 
There  are  a  rise  in  temperature,  an  increase  in  the  pulse  rate, 
loss  of  appetite,  slight  headache,  and  a  feeling  of  general  malaise. 

Treatment. — If  pus  has  not  yet  formed,  the  breast  is  ele- 
vated with  the  bandage  in  such  a  way  that  it  is  firmly  supported 
upward.  (See  Figs.  141  and  142,  page  386.)  This  will  do  much 
to  relieve  the  pain,  but  care  should  be  taken  that  the  binder  is 
not  applied  too  tightly.  Nursing,  as  a  rule,  is  discontinued, 
and  if  the  breast  throbs  and  feels  distended,  the  milk  may  be 
expressed  regularly  either  by  gentle  massage,  the  direction  of 
the  massage  being  a  stroking  motion  from  the  circumference 
of  the  breast  towards  tlie  nipple ;  or  the  milk  may  be  aspirated 
by  a  breast  pump.  During  the  interval,  either  hot  applications 
such  as  flaxseed  poultices  may  be  applied  to  the  breast,  or  cold 
applications  in  the  form  of  a  magnesium  sulphate  solution  of 
50  per  ■  cent,  strength.  When  pus  is  formed  the  abscess  is 
opened  by  the  attending  surgeon  and  freely  drained.  After  the 
acute  suppurative  process  has  subsided  the  drainage  tubes  are 
shortened  gradually  and  the  granulation  tissue  stimulated  by 
silver  nitrate. 

Chronic  Mastitis. — This  condition  is  not  uncommon,  and  pre- 
sumably is  due  to  a  chronic  inflammation  of  the  breast.  The 
patient  complains  of  vague  and  indefinite  pains  localized  in  the 
breast  itself,  and,  on  examination,  there  may  be  found  here 
and  there  some  very  small  nodules  which  may  be  tender.  At 
times  the  lymph  glands  in  the  axilla  (arm-pit)  show  enlarge- 
ment; as  a  matter  of  fact  this  condition  is  frequently  difficult 
to  distinguish  from  cancer  of  the  breast. 

Treatment. — Sometimes  a  well  fitting  breast  binder  will  re- 
lieve much  of  the  pain.  If  there  is  considerable  induration  or 
hardness  of  the  tissue,  warm  fomentations  may  bring  relief. 
Should  these  measures  fail,  most  surgeons  will  remove  that  por- 
tion of  the  breast  which,  is  pathological.     If  at  the  time  of  opera- 


140  TEXTBOOK  OF  SURGICAL  NURSING 

tiou  it  is  tliought  that  the  condition  might  be  cancerous,  the 
entire  breast  and  deeper  tissues  are  removed. 

New  Growths  of  the  Breast. — As  in  other  locations  those 
tumors  Avhich  invade  breast  tissue  may  be  either  benign  or 
maligiiant.  Of  benign  tumors  of  the  breast,  the  most  common 
are  fibroadenomata  ;  these  occur  mainly  in  young  -women ;  they 
are  definitely  encapsulated,  freely  movable,  do  not  gi'ow  beyond 
a  certain  size,  and  cause  no  enlargement  of  the  lymph  glands 
of  the  axilla. 

Treatment. — The  treatment  is  the  excision  of  the  growth, 
with  occasional  drainage  of  the  space  left  by  its  removal  for 
twenty-four  hours. 

Carcinoma. — Carcinoma  of  the  female  mammary  gland  is  rel- 
atively common.  The  rate  of  growth  of  the  tumor  cells  will  vary 
greatly.  Any  mass  in  the  breast  is  strongly  suspicious  of  car- 
cinoma if  it  occurs  after  the  age  of  forty,  and  is  hard,  not  defi- 
nitely encapsulated,  and  attached  to  the  skin  or  deeper  muscular 
layers.  The  glands  in  the  axilla  may  be  enlarged  at  a  very 
early  period.  If  the  disease  has  lasted  for  some  time  the  patient 
may  be  emaciated,  pale,  anemic  and  weak. 

Treatment. — The  treatment  is  radical  excision  of  the  en- 
tire breast  and  the  lymjDh  glands  which  drain  it.  Inasmuch  as 
some  surgeons  perform  a  rather  wide  excision,  the  skin  of  the 
patient  should  be  prepared  from  beneath  the  angle  of  the  jaw 
to  the  umbilicus,  from  well  beyond  the  midline  of  the  affected 
side  to  the  region  beyond  the  axillary  border  of  the  scapula 
(shoulder  blade).  This  preparation,  in  the  main,  will  consist 
of  shaving  the  hair.  Some  surgeons  prefer  no  pre-operative 
preparation  of  the  skin  other  than  that  of  cleansing  it  with 
green  soap  and  water,  leaving  the  iodine  to  be  painted  on  in  the 
operating  room ;  others  will  have  the  skin  cleansed  with  green 
soap  and  water,  followed  by  alcohol,  then  ether,  finally  applying 
sterile  dressings. 

Operation. — The  anesthesia  may  be  given  either  by  the 
Bennet  method  or  intranasally.  A  sandbag  is  placed  beneath 
the  shoulder  blade  of  the  affected  side.  (See  Fig.  75,  page  280.) 
The  arm  may  be  put  out  either  at  right  angles  to  the  body, 
straight,  or  at  right  angles  and  bent  at  the  elbow  to  an  angle 


NURSING  OP  THE  SKIN  AND  APPENDAap]^    141 

of  forty-five  decrees.  Inasmuch  as  many  blood  vessels  are  to 
be  cut,  there  should  be  aji  abundance  of  hemostatic  clamps  and 
catgut  ligatures.  The  surgeon  will  employ  a  drain,  either  the 
tube,  or  cigarette  variety.  After  the  operation,  an  abundance 
of  dressing  is  applied,  for  there  is  apt  to  be  a  great  amount 
of  oozing.  The  arm,  forearm,  and  hand,  as  a  rule,  are  bound 
tightly  to  the  chest. 

Post-operative  Treatment. — As  soon  as  the  patient  recovers 
consciousness  she  is  given  a  backrest,  so  as  to  sit  almost  upright 
in  bed.  As  a  rule,  a  dreissing  is  done  at  the  end  of  twenty-four 
to  forty-eight  hours,  and  the  drainage  tube  removed.  At  this 
dressing  the  arm  is  left  free  out  of  the  bandage,  and  is  held 
in  a  sling  at  right  angles.  The  arm  should  be  given  passive 
movements  carefully  and  gently,  every  two  hours.  The  purpose 
of  this  is  to  diminish  the  adhesions  during  healing  so  that  the 
scar  will  not  limit  the  motion  of  the  arm. 

Patients  are  allowed  up  at  the  end  of  a  week,  and  in  about 
six  weeks  after  operation  X-ray  treatment  is  begun.  This  is 
used  to  kill  some  of  the  cancer  cells  which  may  have  escaped 
the  knife  of  the  operator.  Some  surgeons  at  the  time  of  opera- 
tion will  expose  the  wound  to  radium  for  a  certain  period  of 
time,  doing  the  suturing  later.  Occasionally  the  arm  may  be 
swollen  a  few  weeks  after  operation,  but  it  may  be  lessened 
by  massage  and  bandaging  although  sometimes  in  spite  of  this, 
the  arm  remains  large,  interfering  greatly  with  its  movement. 


CHAPTER  XI 

THE    SURGERY    ANT>    SURGICAL    ITURSING    OF    THE    URINARY 

SYSTEM 

Anatomy. —  The  urinary  system  is  composed  in  a  normal  in- 
dividual, of  the  kidnej'S,  the  ureters,  the  bladder  and  the  urethra. 
The  kidneys,  usuall.y  two  in  number,  are  compound  tubular 
glands.  They  are  situated  on  either  side  of  the  spinal  column 
in  the  region  corresponding  to  the  last  two  thoracic  and  upper 
two  lumbar  vertebrae.  The  right  kidney  is  at  a  lower  level 
than  the  left  owing  to  the  presence  of  the  liver  on  that  side. 
As  a  rule  they  are  about  four  inches  long,  two  and  one-half 
inches  wide,  and  one  and  one-half  inches  thick.  Each  kidney 
is  covered  by  a  capsule.  There  are  cases  in  which  the  kidneys 
are  fused  into  one,  the  horseshoe  kidney ;  or  there  may  be  only 
one  kidney  present. 

The  ureters  which  connect  the  kidneys  to  the  bladder  vary 
from  twelve  to  eighteen  inches  in  length.  The  bladder,  which 
is  the  reservoir  for  the  urine,  is  situated  in  the  pelvis  behind 
the  pubis.  It  is  in  front  of  the  vagina  in  the  female  and  in 
front  of  the  rectum  in  the  male.  It  is  a  muscular  sac,  and  at 
its  neck  gives  origin  to  the  urethra.  The  urethra  is  about  one 
and  one-half  inches  long  in  the  female,  and  eight  to  nine  inches 
in  the  male.  It  courses  beneath  the  symphysis  pubis  in  a  down- 
ward and  forward  direction;  its  external  orifice  in  the  female 
is  situated  between  the  clitoris  and  the  vaginal  opening.  In 
the  male  it  normally  runs  through  the  length  of  the  penis. 

Diseases  of  the  Kidney. — The  inflammatory  affections  of 
the  kidney  may  be  either  of  the  acute  or  chronic  variety.  The 
acute  variety  may  involve  the  pelvis  of  the  kidney  (pyelitis), 
or  there  may  be  pus  formation  in  the  kidney  itself  (suppurative 
nephritis).  If  the  pus  is  retained  in  the  pelvis  with  a  resultant 
dilatation,  the  condition  is  spoken  of  as  a  pyonephrosis. 

142 


NURSING  OF  THE  URINARY  SYSTEM  143 

Of  the  chronic  inflammations,  the  one  which  interests  the  sur- 
geon most  is  tuberculosis. 

Treatment  of  Acute  Infections. — In  pyelitis,  the  treatment 
is  primarily  medical.  The  patient  is  placed  in  bed ;  fluids  are 
forced  to  about  2000  c.c.  a  day,  and  urotropin  gr.  10,  or  more  is 
given  by  mouth  three  times  a  day.  If  it  is  thought  that  the 
pyelitis  is  in  some  way  due  to  a  chronic  constipation  with  a 
dilated  caput  coli,  colon  irrigations  are  especially  indicated. 
Occasionally  the  pelvis  of  the  kidney  is  irrigated  directly 
through  a  ureteral  catheter  which  has  been  introduced  into  the 
ureter  by  means  of  a  cystoscope.  This  is  an  instrument  designed 
to  give  a  view  of  the  interior  of  the  bladder.  It  has  the  general 
shape  of  a  sound,  has  a  telescopic  lens  and  carries  an  electric 
light  to  illuminate  the  interior  of  the  bladder  which  has  been 
previously  distended  with  warm  boric  acid.  It  has  several 
modifications  and  attachments  so  that  small  catheters  may  be 
passed  into  the  ureteral  orifices.  By  this  means  the  urine  from 
both  kidneys  may  be  collected  separately,  and  the  condition  and 
functional  activity  of  each  kidney  may  be  judged. 

In  pyonephrosis,  the  kidney  is  incised  in  the  region  of  the 
pelvis  and  the  pus  removed.  This  operation  is  spoken  of  as  a 
nephrotomy.  But  if  the  kidney  shows  many  areas  of  infec- 
tion, the  so-called  acute  surgical  kidney,  it  may  be  completely 
removed  (nephrectomy). 

Operation  of  Nephrotomy. — The  patient  is  placed  in  the  kid- 
ney position.     This  is  described  in  Chapter  XVI — see  Fig.  67. 

Post-operative  Treatment  of  Nephrotomy. — Inasmuch  as 
urine  as  well  as  pus  will  escape  from  the  kidney  through  the 
wound,  the  dressings  should  be  frequently  removed  and  changed 
to  prevent  maceration  of  the  skin.  The  patient  is  placed  upon 
forced  fluids,  their  amount  carefully  measured,  and  the  urinary 
output  approximately  estimated.  These  cases  are  rather  pro- 
tracted, lasting  from  six  to  eight  weeks.  The  nutrition  should 
be  particularly  watched  and  every  efi^ort  taken  to  maintain  or 
increase  the  patient's  weight  by  a  liberal  diet,  high  in  car- 
bohydrates. When  they  are  allowed  up,  there  is  often  a  leakage 
of  urine  through  the  wound,  and  to  prevent  the  embarrassment 
of  a  constant  urinous  odor,  a  lumbar  urinal  may  be  worn. 


144  TEXTBOOK  OF  SURGICAL  NURSING 

Nephrectomy. — When  it  is  evident  that  the  kidney  has  been 
destroyed  to  such  a  degree  that  it  is  of  little  use  to  the  organism, 
it  is  much  better  to  remove  it  completely.  A  nephrectomy  is 
always  done  for  the  aente  septic  kidney,  dilt'use  pyonephrosis, 
tuberculosis,  or  new  growths,  provided  the  physical  condition  of 
the  patient  will  permit  such  an  operation,  and  the  other  kidney 
is  present  and  not  markedly  diseased.  If  the  ureter  is  definitely 
pathological,  it  is  dissected  do^^^l  until  a  healthy  portion  is 
found,  or  if  the  entire  length  is  affected,  it  might  be  totally 
excised  together  with  the  kidney. 

Post-operative  Treatment. — The  treatment  is  similar  to  that 
of  a  nephrotomy.  The  drainage  tubes  are  removed  at  the  end  of 
three  or  four  days,  and  the  patient  is  kept  in  bed  for  three  to 
four  weeks,  until  the  wound  has  firmly  and  completely  healed. 

Renal  Calculus. — Renal  calculi  or  kidney  stones  may  be 
found  in  the  substance  of  the  kidney,  in  the  pelvis,  or  in  the 
ureter.  The  stones  may  be  single  or  midtiple,  rough  or  smooth, 
and  may  be  present  in  one  or  both  kidneys.  The  symptoms 
which  they  cause  are  those  of  renal  colic.  This  is  a  severe  colicky 
pain  in  the  loin  radiating  downward  to  the  testicle  or  vulva. 
Blood  is  found  in  the  urine  (hematuria)  and  there  is  occa- 
sionally frequency  and  urgency  with  burning  micturition. 

Treatment  of  Renal  Calculus. — Patients  who  have  a  tendency 
to  renal  colic,  as  evidenced  by  a  previous  history  of  attacks,  or 
the  passage  of  small  calculi,  and  whose  urine  contains  an  excess 
of  urates,  should  be  placed  upon  a  diet  which  is  poor  in  protein. 
Alcohol  is  absolutely  prohibited,  also  tea  and  coffee.  Alkaline 
drinks  should  be  administered,  and  the  alkaline  diuretics,  such 
as  acetate,  bicarbonate,  and  citrate  of  potassium  should  be 
given  freely  and  often. 

Operative  Treatment. — When  there  is  definite  evidence  of  a 
stone  from  the  clinical  history  augmented  by  positive  radio- 
graphic and  cystoscopic  findings,  operation  is  indicated,  for  it 
is  the  only  measure  which  will  insure  permanent  relief.  The 
operations  performed  for  kidney  stones  are  two  in  number: — 
nephrolithotomy  and  nephrectomy. 

Nephrolithotomy. — In  this  operation  the  procedure  is  similar 
to  a  nephrotomy.     The  usual  lumbar  incision  is  made  with  the 


NURSING  OF  THE  URINARY  SYSTEM  145 

patient  in  the  kidney  position  (Fig.  65),  the  kidney  exposed, 
and  the  pedicle,  that  is,  the  renal  artery  and  the  renal  vein, 
are  grasped  by  the  hand  of  an  assistant  while  the  surgeon  in- 
cises the  kidney  along  the  convex  border.  Under  these  hemo- 
static conditions  the  bleeding  is  very  little.  The  calices  of  the 
pelvis  and  kidney  tissue  are  carefully  examined  and  the  stone 
removed.  The  kidney  is  sutured  together  with  mattress  sutures 
of  chromic  catgut  on  a  blunt,  non-cutting  needle. 

Post-operative  Treatment. — The  routine  procedure  in  all 
surgical  kidney  cases  demands  that  fluids  be  forced  to  the 
maximum.  All  the  urine  excreted  should  be  accurately  measured 
and  saved  for  the  inspection  of  the  attending  surgeon.  The 
elimination  must  be  especially  watched,  because  after  this  opera- 
tion urinary  suppression  is  apt  to  result.  Should  this  unfortu- 
nate complication  occur,  those  measures  which  are  described  in 
Chapter  III  should  be  instituted  immediately.  For  a  day 
or  so  the  urine  is  apt  to  be  bloody ;  this  is  not  particularly 
alarming.  During  this  period  patients  often  complain  of  sj^mp- 
toms  simulating  renal  colic,  due  to  clotted  blood  passing  down 
through  the  ureter.  The  pain  is  easily  controlled  by  small 
doses  of  morphine  by  hypodermic  injections. 

Operations  upon  the  Ureter. — The  ureter  may  be  incised  to 
remove  a  calculus,  or  it  may  be  removed  for  chronic  diseases, 
such  as  tuberculosis.  The  nursing  is  the  same  as  for  kidney 
cases. 

Urinary  Bladder. — The  bladder  may  be  the  site  of  injury, 
acute  or  chronic  inflammations,  calculi,  or  new  growths. 

Treatment  of  Injuries  of  the  Urinary  Bladder. — The  bladder 
may  be  lacerated  from  external  violence  or  in  fractures  of  the 
pelvis.  In  all  suspected  cases  the  patient  is  placed  under  gen- 
eral anesthesia,  the  bladder  is  examined  through  the  abdominal 
route,  and,  if  injured,  the  damage  is  repaired  by  appropriate 
suture.  As  a  rule,  a  drain  in  placed  down  to  the  injured  area 
of  the  bladder  to  take  care  of  any  urinary  leakage  which  may 
result.  Some  surgeons  insert  a  permanent  catheter  into  the 
urethra;  others  prefer  to  catheterize  the  patient  every  eight 
hours.  In  either  case,  great  care  should  be  taken  that  there  be 
no  undue  intravesical  tension.     Fluids  should  be  administered 


146  TEXTBOOK  OF  SURGICAL  NURSING 

liberall}',  and  during  the  first  week,  urotropin  gr.  10,  or  more 
is  given.     The  patient  is  kept  in  bed  for  at  least  three  weeks. 

Inflammations  of  the  Urinary  Bladder. — Acute  Cystitis. — 
Cj'stitis  may  originate  in  the  bladder  itself,  or  it  may  be  sec- 
ondary to  inflammations  of  the  kidney,  urethra,  or  other  organs. 
The  symptoms  are  frequency  and  urgency  of  micturition,  and 
a  burning  sensation  when  the  urine  is  voided. 

Treatment  of  Acute  Cystitis. — Patients  should  be  kept  in 
bed.  The  pressure  about  the  bladder  is  relieved  by  elevating 
the  pelvis  so  that  the  intestines  will  fall  away  from  it,  and  flex- 
ing the  knees  so  as  to  relax  the  spasm  of  the  rectus  muscles  of 
the  abdomen.  Hot  applications  applied  over  the  bladder  re- 
gion are  very  agreeable,  and  Sitz  baths  given  about  three  times 
daily  afford  great  relief.  If  the  pain  is  very  severe,  morphine 
is  given. 

If  there  is  great  difficulty  in  voiding  because  of  excruciat- 
ing pain,  a  little  novocain  instilled  in  the  posterior  urethra 
affords  great  relief.  Urine  is  less  irritating  when  alkaline,  and 
an  acid  condition  may  be  alkalinized  by  the  giving  of  sodium  bi- 
carbonate or  sodium  citrate,  20  gr.  three  times  a  day.  The 
diet  should  be  bland,  non-irritating,  and  mainly  fluid  in  nature. 
Irrigations  of  the  bladder  may  or  may  not  be  done  according 
to  the  judgment  of  the  surgeon  in  charge.  Irrigating  solutions 
may  be  of  boric  acid,  and  later,  w^hen  the  disease  becomes  less 
acute,  irrigations  of  silver  nitrate  in  distilled  water  may  be 
employed  1-5000,  potassium  permanganate  1-5000,  or  protar- 
gol  1-10,000.  They  are  more  effective  and  comforting  when 
given  warm. 

Chronic  Cystitis. — Chronic  inflammations  of  the  bladder  may 
be  the  result  of  an  acute  attack,  or  secondary  to  some  condi- 
tion in  the  bladder  itself,  as  a  papilloma  or  a  stone. 

Treatment. — The  treatment  is  that  employed  in  the  late 
stages  of  acute  inflammation,  namely,  irrigations.  These  should 
be  given  daily,  after  a  diagnosis  of  its  etiology  has  been  made. 
Sometimes,  because  of  stricture  of  the  uiethra  or  inflamma- 
tion of  the  testes,  irrigations  are  not  practical.  These  cases  are 
treated  by  cystotomy  (a  suprapubic  incision  into  the  bladder 
with  the  establishment  of  free  continual  drainage). 


NURSING  OF  THE  URINARY  SYSTEM  147 

Primary  tuberculosis  of  the  urinary  bladder  is  extremely 
rare ;  it  is  ordinarily  infected  secondary  to  the  kidney,  prostate, 
or  testis.  The  complaints  given  are  usually  of  frequency, 
urgency,  and  often  bloody  urine. 

Treatment  of  Tuberculosis  of  Urinary  Bladder. — The  treat- 
ment, of  course,  should  be  directed  to  the  primary  focus  of  the 
tubercle  bacillus,  and,  if  the  kidney  is  responsible,  it  should 
be  extirpated.  While  this  is  of  prime  importance,  the  patient 
meanwhile  must  receive  some  treatment  to  relieve  the  very  dis- 
tressing symptoms  of  a  diseased  bladder.  In  the  first  place  the 
patient  should  be  kept  in  good  hygienic  surroundings.  Food 
should  be  plentiful,  appetizing,  and  highly  nutritious,  and  every 
measure  available  should  be  taken  to  insure  the  strengthening  of 
a  weakened,  debilitated  constitution.  The  bladder  should  be 
irrigated  with  very  hot  solutions  of  boric  acid.  These  are  al- 
ways pleasing,  and  will  relieve  much  of  the  pain.  If  the  pain 
is  very  severe,  some  novocain  (but  never  cocaine)  might  be 
instilled  into  the  bladder.  Tuberculous  bladders  are  ulcerated, 
and  great  care  must  be  taken  that  too  much  medication  is  not 
instilled,  because  free  absorption  is  apt  to  take  place  and  poison- 
ing result.  Rectal  suppositories  containing  opium  and  extract 
of  belladonna  do  much  to  relieve  pain. 

Operative  Treatment. — This  consists  in  a  suprapubic  cys- 
totomy and  the  direct  treatment  of  the  ulcerated  bladder 
mucosa,  either  with  the  actual  cautery  or  chemical  caustics. 
The  after  treatment  is  very  important.  The  foot  of  the  bed 
is  raised,  the  bladder  drained  by  continuous  drainage,  and 
washed  out  daily  with  a  bland  non-irritating  solution  through 
the  suprapubic  tube.  Drainage  of  the  bladder  is  kept  up  for 
about  six  weeks.  It  is  important  to  maintain  all  the  rules  of 
strict  asepsis  in  these  cases,  for  nothing  is  more  discouraging 
than  to  add  secondary  infection. 

Bladder  Stone. — "When  a  stone  is  present  in  the  bladder, 
there  are  generally  pain,  frequency  of  urination,  and  the  occa- 
sional passage  of  blood  at  the  end  of  micturition.  The  diagnosis 
of  bladder  calculi  is  not  so  difficult  since  the  use  of  the  X-ray 
and  cystoscope,  although  formerly  its  presence  was  detected 
by  the  metal  sound  stone  searcher  of  Thompson. 


148  TEXTBOOK  OF  SURGICAL  NTJRSINft 

Treatment. — The  stone  is  either  removed  by  lithotomy  or 

lithohipaxy. 

Litholapaxy. — The  patient  is  placed  in  the  lithotomy  posi- 
tion (i^'i^.  72)  and  the  urethra  locally  anesthetized.  Some  em- 
ploy spinal  anesthesia,  and  others,  general.  In  this  procedure 
an  attempt  is  made  to  crush  the  stone  ^vithin  the  bladder  by 
means  of  a  lithotrite.  This  is  an  instrument  introduced  through 
the  urethra,  and  then  opened  when  in  the  bladder,  grasping  the 
stone  between  its  two  powerful  jaws,  and  crushing  it  into 
smaller  pieces.  The  stony  fragments  are  later  evacuated  by  means 
of  a  Bigelow  evaeuator,  which  is  an  instrument  designed  to  suck 
from  the  bladder  the  stone  fragments  in  a  water  current. 

Post-operatively,  water  should  be  given  in  large  amounts; 
the  urine  should  be  kept  acid,  and  drainage  from  the  bladder 
should  be  free,  through  an  inlying  catheter.  As  a  rule  this  can 
be  removed  at  the  end  of  forty-eight  hours. 

Suprapubic  Lithotomy. — In  this  operation  the  bladder  is 
opened  above  the  pubis ;  the  stone  is  removed,  and  the  bladder 
sutured. 

Ante-operative  Treatment  and  Operation. — This  consists  of 
the  ordinary  preparation  for  any  abdominal  operation.  The 
patient  is  anesthetized,  the  bladder  is  distended  fully  wdth  either 
warm  boric  acid  solution  or  air.  and  the  patient  is  placed  in 
the  Trendelenburg  position  (Fig,  63),  A  suprapubic  median 
incision  is  made,  the  bladder  exposed,  incised,  and  the  stone 
removed  with  special  forceps.  The  bladder  is  sutured  with  a 
double  row  of  sutures,  and  the  abdominal  wound  closed. 

Post-operative  Treatment. — If  tlie  wound  is  sutured  tightly, 
the  patient  may  be  permitted  up  in  from  ten  to  fourteen  days. 
If  there  is  suprapubic  drainage  because  of  a  concomitant 
cystitis,  the  tube  should  be  left  in  for  about  ten  days,  and  then 
removed;  the  patient- is  allowed  up  as  soon  as  the  suprapubic 
Avound  has  healed.  With  very  old  people,  attempts  should  be 
made  to  get  them  out  of  bed  as  soon  as  possible,  for  experience 
has  shown  that  a  weakly  healed  abdominal  wound  is  better 
than  broncho-pneumonia  and  death  wdiich  may  result  if  these 
cases  are  confined  to  bed. 

New  Growths  of  the  Urinary  Bladder. — Tumors  of  the  blad- 


NURSING  OF  THE  URINARY  SYSTEM  149 

der  may  be  either  benign  or  malignant ;  the  benign  variety 
may  be  treated  through  the  cystoscope,  or  by  open  operation; 
the  malignant  ones  by  open  operation  and  radium. 

Cystoscopic  Treatment. — This  is  especially  adaptable  for 
cases  of  small  benign  tumors  of  the  papillomatous  variety.  These 
growths  are  located  with  the  cystoscope  and  fulgurated  with  the 
sparks  of  a  high  frequency  current  under  direct  vision.  The 
effect  is  simply  to  burn  away  the  tumor  tissues. 

Operation. — A  suprapubic  cystotomy  is  done,  and  an  effort 
made  to  extirpate  the  growth  under  direct  vision  by  excision. 
In  cases  of  extensive  malignant  growths  the  bladder  may  be 
excised  in  its  entirety.  The  ureters  may  either  be  transplanted 
in  the  rectum  or  brought  to  the  skin  surface  through  the  ab- 
dominal wall.  This  is  an  operation  of  considerable  risk,  the 
mortality  is  high,  and  the  end  results  extremely  poor.  When 
extensive  cancer  exists  it  is  much  better  to  employ  radium. 

Eadium  Treatment. — The  solid  radium,  enclosed  within  a 
metallic  tube  of  platinum,  is  introduced  into  the  bladder  through 
a  suprapubic  incision,  and  left  in  place  for  a  certain  number 
of  hours,  or  it  may  be  introduced  through  the  urethra  with  a 
special  cystoscopic  arrangement. 

These  cases  are  often  apt  to  hemorrhage.  The  bleeding  is 
effectively  controlled  by  irrigation  of  the  bladder  with  warm 
boric  acid  and  the  introduction  thereafter  of  a  1-1000  solu- 
tion of  adrenalin  hydrochloride. 

It  is  quite  natural  that  such  patients  are  nervous  and  ap- 
prehensive, but  every  attempt  should  be  made  to  reassure  them, 
rather  than  administer  morphine,  for  in  these  chronic  cases 
the  opium  habit  is  established  very  easih^,  and,  in  addition,  this 
drug  has  a  depressive  action  on  the  kidneys. 

The  Urethra. — The  diseases  of  the  male  urethra  are  usually 
treated  by  the  surgeon  himself,  and  as  the  lesions  of  the  female 
urethra  demand  practically  no  operative  interference,  the  only 
condition  which  requires  mention  is  stricture  of  the  urethra. 
This  develops  secondary  to  acute  inflammations  of  the  urethral 
canal  in  which  the  mucous  membrane  has  been  partially  de- 
stroyed, and  its  place  is  taken  by  scar  tissue.  When  this  tis- 
sue contracts  it  form§  a  stricture,  narrowing  the  lumen,  result- 


150  TEXTBOOK  OF  SURGICAL  NURSING      ' 

iiig  iu  difficult  micturition,  and  often  complete  retention  of 
urine.  To  relieve  this,  if  catheterization  is  impossible,  a  ure- 
throtomy ,is  performed.  If  the  constriction  is  in  the  penile 
portion  an  internal  urethrotomy  is  performed;  if  in  the  deep 
urethra,  an  external  urethrotomy. 

Internal  Urethrotomy. — An  internal  urethrotomy  consists  of 
cutting  the  stricture  Avith  an  urethrotome  (an  instrument  shaped 
like  a  sound  containing  a  hidden  knife).  The  urethrotome 
is  introduced  into  the  region  of  the  stricture,  the  knife  drawn^ 
and  the  stricture  cut.  Sounds  are  then  passed  and  the  strictured 
area  dilated  to  the  calibre  desired. 

External  Urethrotomy. — The  patient  is  placed  in  a  lithotomy 
position,  a  filiform  bougie  is  passed  into  the  penis,  and  an  at- 
tempt made  to  pass  it  through  the  strictured  area.  A  tunnel 
sound  is  threaded  along  the  filiform  bougie  down  to  the  stric- 
tured area,  the  perineum  is  incised  over  the  sound,  and  the 
stricture,  identified  by  means  of  the  filiform,  is  cut  with  a  spe- 
cial urethrotomy  knife.  A  tube  is  passed  into  the  bladder 
through  the  perineal  incision. 

Post-operatively  this  tube  is  connected  with  bottle  drainage. 
Fluids  are  forced  and  in  about  one  week  the  tube  is  withdrawn 
and  the  patient  is  encouraged  to  void  through  the  urethra. 
Sounds  are  passed  about  twice  a  week. 

Circumcision. — This  operation  is  performed  to  relieve  a 
tight  prepuce  (phimosis),  and  consists  in  trimming  off  the  re- 
dundant skin  and  mucous  membrane  of  the  penis.  In  young 
children  the  nurse  should  change  the  dressing  after  urination. 


CHAPTER  XII 

SURGICAL   DIETETICS 

Diet  is  indeed  a  most  important  post-operative  considera- 
tion. No  two  patients  can  be  nourished  alike,  and  it  is  a 
grave  mistake  to  feed  them  in  a  routine  manner  as  is  so  often 
done.  The  type  of  operation  performed,  the  physical  condition, 
the  age,  and  the  general  post-operative  behavior  are  all  im- 
portant factors  in  determining  the  kind  of  food,  the  amount 
and  the  frequency  of  the  feedings.  Patients  who  have  had  a 
colostomy  performed  certainly  must  be  dieted  differently  from 
those  who  have  had  a  gastroenterostomy.  A  woman  of  sixty 
will  not  be  able  to  digest  the  regular  hospital  diet  with  the 
ease  of  a  young  boy.  Then  again,  while  the  diet  may  be  per- 
fect when  under  supervision  of  the  nurse,  obliging  relatives 
and  kind  friends  may  bring  food  and  delicacies  which  may 
prove  detrimental  to  the  health  of  the  patient.  It  is  not  un- 
usual to  see  gastric  disturbances  after  visiting  days,  due  to 
candy  and  fruit  which  have  been  smuggled  in  by  visitors. 
This  evil  should  be  tactfully  and  carefully  controlled. 

In  the  discussion  of  surgical  dietetics,  to  facilitate  matters, 
it  will  be  best  to  first  consider  the  diet  following  a  simple  opera- 
tion, such  as  hernia,  appendicectomy,  ventral  suspension  of  the 
uterus,  and  simple  plastic  gynecological  operations. 

Liquid  Diet. — After  a  patient  has  recovered  from  the  anes- 
thetic, he  asks  for  water,  and  inasmuch  as  there  is  bound  to 
be  nausea  and  vomiting  following  most  operations,  water  is  not 
permitted  until  two  hours  after  the  last  vomiting.  Of  course, 
it  is  rather  difficult  to  judge  which  is  the  last  vomiting,  but 
this  can  be  learned  by  experience.  As  a  rule,  water  is  given 
in  teaspoonful  doses,  moderately  warm,  although  some  surgeons 
will  order  it  ice  cold.  If  the  patient  tolerates  this  well,  more 
may  be  given  if  desired,  but  he  should  never  be  allowed  to  drink 

151 


152  TEXTBOOK  OF  SURGICAL  NURSING 

promiscuously  and  I'reel}'.  It  is  not  advisable  to  alluAv  tiuids 
or  ' '  liquid  diet ' '  until  the  day  following  operation.  The  liquids 
commonly  used  are  broths,  gruels,  tea,  egg  albumen,  and  lemon 
juice.  About  five  ounces  of  these  are  given  at  a  time.  The 
second  day  after  operation,  milk  may  be  added. 

Milk  is  almost  a  perfect  food;  it  is  quickly  delivered  to  the 
stomach,  is  entirely  absorbed,  has  a  high  caloric  value  and 
provides  considerable  nourishment.  There  are  some  people  who 
cannot  tolerate  plain  whole  milk.  This  may  be  remedied  oc- 
casionally by  adding  barley  water,  lime  water,  plain  water, 
seltzer,  vichy,  or  a  little  brandy. 

While  it  is  not  good  policy  to  use  alcoholic  beverages,  such 
as  brandy  or  Avhisky,  sudden  withdrawal  of  these  from  patients 
who  have  been  accustomed  to  alcohol  for  j^ears  might  bring  on 
delirium  tremens.  For  these  chronically  alcoholic  individuals  it 
is  sometimes  advisable  to  give  one-half  to  one  ounce  of  whisky 
three  times  a  daj^  On  the  other  hand,  some  surgeons  use  it 
as  a  stimulant,  prescribing  it  for  weak  and  debilitated  patients 
the  first  few  days  after  operation. 

The  fluids  should  be  served  at  frequent  intervals  according 
to  the  desire  of  the  patient ;  whenever  possible  they  should  be 
served  warm  and  always  attractively.  If  they  do  not  agree 
with  the  patient,  and  cause  vomiting,  their  administration  should 
cease.  On  the  third  day,  as  a  rule,  after  the  patient's  bowels 
have  been  moved  either  by  a  cathartic  or  by  an  enema,  a  se- 
lected soft  diet  is  allowed. 

Soft  Diet. — The  following  foods  are  appropriate  for  a  soft 
diet.  It  may  be  varied  and  grouped  according  to  the  taste  of 
the  patient : 

Cereals: — .Wlieatena,   hominy,    oatmeal,   cornmeal,   farnia,   cream   of 

wheat. 
Eggs : — Soft  boiled. 

Vegetables: — Baked,  mashed,  or  boiled  potatoes. 
Macaroni. 
Desserts : — Ice   cream,    baked    custard,   rice,    tapioca,    or   cornstarch 

pudding. 

If  this  is  well  borne,  within  another  day  the  patient  may  be 
shifted  to  a  convalescent  diet. 


SURGICAL  DIETETICS 


15;^ 


Convalescent  Diet.     For  each  day  of  the  week. 

Total  quantity  of  milk  allowed  not  ovei'  1250  e.c.   (21/2  pints)  daily. 
6:00  a.m.     Milk,  210  e.c.  (7  ounces)  if  desired. 

Breakfast 

Coffee  or  tea,  with  milk  and  sugar,  or  milk. 

One  egg,  or  fresh  fish,  or  plain  stew. 

Cereal  with  milk  and  sugar. 

Toast  and  butter,  or  rolls  or  bread  (white,  graham,  or  brown). 

Dinner 

Broth  or  soup  with  barley  or  vegetables. 

Bread  and  butter.     Milk. 

Potatoes,  baked,  boiled,  or  mashed. 

Rice,  macaroni,  or  hominy. 

Beef,  chicken,  or  fish. 

Pudding,  ice  cream,  or  fruit. 

Supper 

Tea  or  milk.     Toast  and  butter,  or  bread. 
Egg. 

Cooked  fruit    (baked  or  stewed   apples,   prunes,   rhubarb,   apricots, 
pears). 

At  8:00  p.m.,  milk,  210  e.c.  (7  ounces). 
Particular  Foods  for  Specified  Days. 

Sunday 


Breakfast 

Dinner 

Supper 

Wheatena 
One  egg  ' 

Chicken 
Baked  potato 
Orange 

Monday 

Egg 
Prunes 

Breakfast 

Dinner 

Supper 

Hominy 

Stew 

Roast-beef 
Mashed  potato 
Rice  pudding , 

Tuesday 

Egg 

Pears  or  apri 

Breakfast 

Dinner 

Supper 

Oatmeal 

Egg 

Fresh  fish,  hominy 
Boiled   potato 
Ice  cream 

Egg 

Stewed  apples 

154 


TEXTBOOK  OF  SURGICAL  NURSING 


Wednesday 

Breakfast 

Dinner 

Supper 

AYlieatena 

Chicken,  baked  potato 

Eg'g 

Fresh  fish 

Macaroni 
Tapioca  pudding 

Thursday 

Rhubarb  or  prune 

Breakfast 

Dinner 

Supper 

Hominy 

Boiled  beef,  rice 

Egg 

Egg 

Mashed  potato 
Baked   custard 

Friday 

Baked  apple 

Breakfast 

Dinner 

Supper 

Oatmeal 

Fresh  fish 

Eggs 

Egg 

Boiled  potato 
Macaroni 
Ice  cream 

Saturday 

Prunes 

Breakfast 

Dinner 

Supper 

Cornmeal 

Chicken 

Egg 

Stew 

Mashed  potato 
Hominy 
Cornstarch  pudding 

Apricots  or  pears 

Approximate  values  to  be  given. 

Protein         Carbohydrates 

Men    100  gm.  300  gm. 

Women     80  gm.  300  gm. 


Fat      Total  Calories 
90  gm.  2500 

80  2m.  2200 


Regular  Diet. — This  should  be  composed  of  the  food  to  vrhich 
the  patient  is  normally  accustomed,  and  should  consist  of  a 
good  mixed  diet.  It  is  not  necessary  to  outline  it  in  detail. 
Those  foods  should  be  selected  which  the  patient  enjoys,  which 
are  easily  digestible  and  which  need  not  be  fried  in  fat.  An 
example  of  such  a  diet  is  the  following  one: 


SURGICAL  DIETETICS  155 

Total  quantity  of  milk  allowed  must  not  exceed  750  c.e.  or  iy2  jjints. 

Breakfast 

Coffee  or  tea  with  milk  and  sugar,  or  milk. 

Bread  and  butter. 

Two  eggs  to  each  patient  in  male  wards. 

One  egg  to  each  patient  in  female  wards. 

Cereal  with  milk  and  sugar. 

Fresh  fish.     Hash. 

Dinner 
Soup 

Meat  or  fish 

Potatoes,  baked,  boiled,   or  mashed.     Bread   and  butter. 
Spinach,  squash,   boiled   onions,   beets,   sweet  potatoes,  macaroni,  to- 
matoes, corn. 
Pudding,  or  fruit.     Milk,  180  c.c.  or  6  ounces. 

Supper 

Tea  or  milk.     Bread  and  butter. 

Cooked  fruit   (prunes,  apples,  rhubarb,  apricots,  pears). 

Cold  meat.     Eggs. 

Cereal  with  milk  and  sugar.    Milk  toast. 

Diet  for  Diabetes. — When  certain  diseases,  such  as  diabetes 
or  nephritis,  complicate  surgical  conditions,  the  patient  often 
undergoes  a  pre-operative  dietetic  preparation,  so  that  the 
best  possible  physical  state  is  attained  before  the  operation  is 
performed.  It  is  a  well-known  fact  that  patients  who  suffer  from 
diabetes  mellitus,  a  disease  in  which  the  sugar  content  of  the 
blood  is  high,  and  sugar  appears  in  the  urine,  are  extremely 
poor  operative  risks.  To  begin  with,  they  take  their  anes- 
thetic poorly,  their  tissues  are  rather  low  in  vitality,  become 
infected  very  easily,  and  are  slow  in  healing.  Then  after  opera- 
tion, they  are  apt  to  pass  into  a  diabetic  coma,  a  very  serious 
complication,  usually  resulting  in  death.  In-order  to  give  these 
patients  the  best  post-operative  chance  by  rendering  them  less 
liable  to  coma,  infection,  and  slow  wound  healing,  every  at- 
tempt should  be  made  to  reduce  their  diabetes  to  the  minimum, 
or  to  render  them  sugar  free.  The  following  list  of  diets  are 
those  which  are  usually  prescribed  or  ordered  by  surgeons  to  ac- 
complish these  ends. 


156  TEXTBOOK  OF  SURGICAL  NURSING 

Standard  Strict  Diet. 

Breakfast 

2  eggs.     Coffee  with  45  gm.  cream. 
Hani,  90  gm. 

Butter,  15  gm.  on  biscuit  during  the  test  period;  cooked  with  the 
eggs  if  no  biscuit  or  bread  is  taken. 

Luncheon 

Meat,  steak  or  chops,  120  gms. 

Green  vegetables  (from  list),  2  tablespoonfuls. 

Butter,  15  gm.  with  green  vegetable  if  no  biscuit  or  bread  is  taken. 

White  wine,  2  claret  glasses,  or  whisky  or  brandy,  2  tablespoonfuls. 

Afternoon  tea  with  15  gm.  of  cream. 

Dinner 

Clear  soup. 

Fish,  90  gm. 

Meat,  beef,  mutton,  turkey,  or  chicken,  120  gm. 

Green  vegetable,  2  tablespoonfuls. 

Salad  with  15  gm.  of  oil  in  the  dressing.     Cream  cheese,  30  gin. 

Butter,  30  gm.  on  fish,  meat,  or  vegetables  if  no  bread  or  biscuit 

taken. 
White  wine,  2  claret  glasses,  or  whisky  or  brandy,  2  tablespoonfuls. 
Demi-tasse. 

Bedtime 

Bouillon  with  one  raw  egg. 

Protein,  112  gm.;  nitrogen,  18  gm. ;  fats,  160  gm.;  calories,  2200; 
omitting  ham,  protein,  94  gm.;  nitrogen,  15  gm. 

For  convenience  in  determining  the  carbohydrate  tolerance,  the  fol- 
lowing biscuits  may  be  used,  as  the  percentage  of  carbohydrates 
is  practically  constant : — Huntley  and  Palmer  breakfast  biscuit 
which  contains  5  gm,  carbohydrate;  Uneeda  Biscuit,  which  contains 
4.6  gm.  carbohydrate. 

Standard  Diet  with  Restricted  Protein. 

Breakfast 

2  eggs.     Bacon,  15  gm.     Butter,  20  gm. 

Coffee  with  45  gm.  of  cream. 

Luncheon 

1  eg^.     Bacon,  15  gm. 

Lamb  chops,  ham,,  or  beefsteak,  60  gm.     Butter,  40  gm. 

Salad  with  15  gm.  of  oil  in  dressing. 

White  wine,  2  claret  glasses,  or  whisky  or  brandy,  2  tablespoonfuls. 


SURGICAL  DIETETICS  157 

Afternoon  tea  with  15  gm.  of  cream. 

Dinner 

Clear  soup. 

Butter,  30  gm. 

Roast  pork,  beef,  mutton,  turkey,  or  lamb  chops,  90  gms. 

Green  vegetables. 

Salad  with  15  gm.  of  oil  in  dressing.     Cream  cheese,  30  gtn. 

White  wine,  2  claret  glasses,  or  whisky  or  brandy,  2  tablespoonfuls. 

Demi-tasse. 

Bedtime  , 

Bouillon  with  one  raw  egg. 

Protein,  62  gm. ;  nitrogen,  10  gm.;  fat,  180  gm.;  total  calories,  2500. 

Omitting  30  gm.  of  butter  and  y2  ounce  of  bacon,  calories  equal  2250. 

Green  Days. 

Breakfast 

1  egg,  boiled  or  poached.     Cupful  of  black  coffee. 

Dinner 

Spinach  with  hard  boiled  egg.     Bacon,  15  gm.     Salad  with  15  gm. 

of  oil. 
White  wine,  %^  liter,  or  whisky  or  brandy,  30  c.c. 

4 :30  p.  m.     Cup  of  beef  tea  or  chicken  broth. 

Supper 

1  egg,  scrambled  with  tomato  and  a  little  butter.     Bacon,  15  gm. 
Cabbage,  cauliflower,  sauerkraut,  string  beans,   or  asparagus. 
White  wine,  or  whisky  or  brandy,  30  c.c. 
Sodium  bicarbonate,  15  to  30  gm.  in  24  hours. 

Protein,  32  gm. ;   nitrogen,  5  gm.;  carbohydrate  about  5  gm. ;   fat, 
67  gm.;  calories,  575. 

General  Diabetic  Diet  List. 

(May  take  freely.) 

Soups.  All  meat  soups  and  broths  to  which  vegetables,  egg 

or  cheese  may  be  added. 

Meats.  All    fresh,    smoked,    and    cured    meats    except    liver, 

poultry  and  game,  without  sauces  or  gravies  con- 
taining flour. 

Fish.  All  kinds  except  oysters,  clams  and  scallops,  cooked 

without  bread  crumbs  or  meal;  all  dried,  salted, 
smoked  or  pickled  fish. 


158 


TEXTBOOK  OF  SURGICAL  NURSING   ' 


Eggs. 
Fats. 
Cheese, 


Salads  and 
Vegetables. 


Prepared  in  any  ■way  withont  flonr. 
Bntter,  lard,  suet,  olive  oil,  or  other  fats. 
All  kinds,  especially  cream,  Swiss,  English  and  pine- 
apple. 
Beet  greens,  Brussels  sprouts,  cabbage,   cauliflower, 
celery,  chicory,  cresses,  cucumbers,  egg-plant,  en- 
dive,    kohlrabi,     leeks,     lettuce,     okra,     pumpkin, 
radishes,    rhubarb,    salsify,    sauerkraut,    spinach, 
string-beans,  tomatoes,  and  vegetable  marrow. 
Pickles  made  from  these  vegetables  unsweetened; 
ripe  olives. 
Mushrooms  and  truffles. 

Salt,  pepper,  cayenne,  paprika,  curry,  cinnamon, 
cloves,  English  mustard,  nutmeg,  caraway,  capers, 
vinegar,  and  piquant  sauces  in  small  quantities. 
Jellies  made  from  gelatin,  custards  and  ice  cream 
made  with  eggs  and  cream ;  all  sweetened  with  sac- 
charin and  flavored  with  vanilla,  coffee  or  brandy. 
Butternuts. 

Not  over  90  c.c.  a  day. 

Tea   or  eofl^ee,    sweetened   with   saccharin   and   with 
portion  of  cream  allowed.     Whisky,  brandy,  rum, 
and  other  distilled  liquors  up  to  3  oi;nces  a  day. 
Light  wine  or  Moselle  wine,   claret  or  Burgundy 
up   to  16   ounces   a   day.     Mineral  waters   of  all 
kinds.     Lemonade    in    small    quantity    sweetened 
with  saccharin. 
Articles  Prohibited.     (Except  as  prescribed  in  the  Accessory  Diet.) 
Sugars  and  sweets  of  every  kind. 
Pastry,  puddings,  preserves,  cake  and  ice  cream. 
Bread,  biscuits,  toast,  crackers,  and  griddle  cakes. 
Cereals  such   as  rice,   oatmeal,   sago,   hominy,   tapioca,   barley  and 

macaroni. 
Vegetables  such  as  potatoes,  carrots,  parsnips,  beans,  peas,  beets, 

green  corn,  and  turnijos. 
Fruit.     Neither  fresh  nor  dried. 
Soups,  sauces  or  gravies  thickened  with  flour  or  meal,  or  made  with 

milk. 
Beer,  ale,  porter,  all  sweet  wines,  sherry  or  port  wine,  sparkling 

wines,  cider  and  liquors. 
Milk,  chocolate  or  cocoa. 
Soda  water  and  all  sweet  drinks. 


Fungi. 
Condiments. 


Dessert. 


Nuts. 

Cream. 

Beverages. 


SURGICAL  DIETETICS  159 

Oatmeal  Days. 

Porridge  made  from  oatmeal,  250  gm.  with  butter,  250  gm.,  salt 
and  pepper. 

Black  coffee,  light  wine  ^  liter,  or  cognac,  60  c.c. 

The  whites  of  6  eggs  may  be  added  to  the  porridge  if  desired. 

Nitrogen  gm.     Carbohydrate  gm.  Calories 

Oatmeal 6.2                          170  1025 

Butter    0.4  1975 

6.6  or  42  gm.  protein  3000 

Alcohol   (40  gm.)    ...  ■  210 

6  whites  of  eggs   ....  3.6  90 

10.2  or  63  gm.  protein  3300 

The  entire  diet  consists  of: — Protein,  63  gm.;  nitrogen,  16.8  gm.; 
carbohydrate,  170  gm. ;  fat,  212  gm.;  calories,  3300. 

Diet  for  Patients  with  Nephritis. 

Occasionally  patients  with  severe  nephritis  have  to  undergo 
operations;  or,  if-  they  are  operated  on  in  an  emergency,  their 
post-operative  care  is  partially  one  of  diet.  It  is  a  known  fact 
that  salt  or  sodium  chloride  is  retained  in  the  body  in  cases  of 
kidney  disease,  and  that  its  retention  causes  edema.  Occasion- 
ally if  there  is  a  sodium  chloride  retention  it  is  necessary  to  put 
the  patient  upon  a  salt  poor  diet.  These  may  be  of  three  general 
varieties.  The  important  factor  in  all  is  that  the  food  should  be 
prepared  without  any  salt  and  that  the  butter  and  bread  are  to 
be  salt  free  and  that  no  extra  salt  should  be  allowed. 

Salt  Poor  Diet.    1. 

Breakfast 

Bread,  30  gm.  or  1  oz.     Sugar,  10  gm.  or  ^/^  oz.    Farina,  60  gm.  or 

2  oz. 
Butter,  30  gm.  or  1  oz.     ]   egg  or  40  gm.  or  l^/j  oz.     Coffee,  150 

c.c.  or  5  oz. 

Total,  320  gm.  or  IOV3  oz. 

Dinner 

Bread,  30  gm.  or  1  oz.     Butter,  20  gm.  or  2/3  oz.     Sugar,  10  gm, 

or  ^/g  oz. 
Rice,  60  gm.  or  2  oz.     Farina,  100  gm.  or  3^/3  oz.     Tea,  150  c.c. 

or  5  oz. 

Total,  370  gm.  or  I2Y3  oz. 


160  TEXTBOOK  OF  SURGICAL  NURSING 

Supper 

1  egg  or  4U  giu.  or  1'/.,  oz.     Toast,  15  gm.  or  i/o  oz.     Bread,  30  iiui 

or  1  oz. 
Butter,  15  gui.  or  l^/^  oz.     Custard,  100  gm.  or  3^/^  oz.     Prunes, 

60  g:ni.  or  2  oz. 
Tea,  ISO  c.c.  or  6  oz. 

Total,  440  gm.  or  I4-/3  oz. 
This  contains  chlorides,  1  gm.,  protein,  35  g:m.  or  1^/^  oz.     Fat, 

65  gm.  or  2^/^  oz.     Carbohydrate,  140  gm.  or  4-/3  oz.     Calories, 

1300. 

Salt  Poor  Diet.    2. 

Breakfast 

Bread,  60  gm.  or  2  oz.     Sugar,  40  gm.  or  IY3  oz.     Farina,  60  gm. 

or  2  oz. 
Butter,  35  gin.  or  1^/g  oz.     1  egg,  40  gm.  or  1^/3  oz.     Coffee,  150 

c.c.  or  5  oz. 

Total,  385  gm.  or  12Vg  oz. 

Diuuer 

One  egg,  40  gm.  or  IY3  oz.     Bread,  60  gm.  or  2  oz.     Butter,  30  gm. 

or  1  oz. 
Rice,  70  g-m.  or  2Y3  oz.     Farina,  100  gm.  or  3^/3  oz.     Tea,  150 

c.c.  or  5  oz. 

Total,  450  gm.  or  15  oz. 

SMp2Jer 

One  egg  or  40  gm.  or  1^/3  oz.     Bread,  60  gm.  or  2  oz.     Butter,  30 

gm.  or  1  oz. 
Custard,  100  gm.  or  3Y3  oz.     Prunes,  60  gm.  or  2  oz.     Tea,  180 

c.c.  or  6  oz. 

Total,  485  gm.  or  15^/^  oz. 
This  contains  chlorides,  3  gm.;  protein,  50  gm,  or  1^/3  oz. ;  fat,  100 

gm.  or  31/3  oz. ;  carljohydi-ate,  240  gm.  or  8  oz. ;  calories,  2100 

Salt  Poor  Diet.     3. 

This  is  the  same  as  the  convalescent  diet  without  broths  or  soups. 
The  fish,  meat  and  green  vegetables  must  be  boiled  in  two  waters 
to' remove  most  of  the  salt.     Milk,  250  c.c.  or  8  oz.  only  allowed. 

Diet  in  Gastric  Cases. — The  diet  following  stomach  opera- 
tions is  dependent  upon  what  has  been  done  surgically.  If  the 
ulcer-bearing  area  has  been  removed,  it  is  not  essential  to  place 


SURGICAL  DIETETICS  161 

this  patient  upon  an  elaborate  gastric  diet.     The  routine  in 
these  eases  is  as  follows : 

For  the  first  twenty-four  hours,  the  patient  is  given  nothing 
by  mouth,  water  being  freely  administered  by  Murphy  drip. 
Then,  water  by  mouth  is  given  in  dram  doses  every  hour; 
and,  if  tolerated,  after  two  doses,  it  is  increased  to  half  an 
ounce,  alternating  with  peptonized  milk, — one-half  ounce  every 
two  hours.  Thus  the  patient  obtains  something  every  hour.  If 
this  is  well  borne,  after  four  feedings,  the  amount  is  increased 
to  one  and  then  to  two  ounces.  Then  easily  digested  substances 
are  added,  such  as : 

Farina,  rice,  sago,  soft  eggs;  thin  soups,  consomme  or  bouil- 
lon, baked  or  mashed  potatoes;  soft  vegetables  such  as  beans, 
peas ;  and  buttered  toast ;  cocoa. 

After  a  period  of  two  weeks  or  more  these  articles  may  be 
eaten : 

Lamb  or  chicken  in  moderate  amounts  about  two  times  a 
week;  fresh  fish  either  boiled  or  broiled,  never  fried;  lettuce, 
water  cress,  romaine,  endive,  chicory  with  a  good  quantity  of 
olive  oil  and  very  little  vinegar;  desserts,  such  as  ice  creams 
and  custards. 

It  is  highly  important  that  the  following  foods  he  omitted: 

Coarser  vegetables  such  as  cabbage,  cucumbers,  kohlrabi, 
tomatoes,  onions,  celery,  corn,  cauliflower,  sprouts,  artichokes, 
asparagus  and  beets.  Also  veal,  pork,  corned  or  smoked  meats, 
lobster,  crabs,  shrimps,  cheese  excepting  Philadelphia  or  Neucha- 
tel,  pickles,  too  hot  or  too  cold  drinks,  strong  tea  or  coffee,  too 
much  pastry,  especially  those  cooked  in  fat,  such  as  fritters, 
doughnuts ;  jams,  cherries,  cranberries  and  muskmelons. 

Meat  should  be  roasted  or  broiled;  never  fried. 

Those  cases  in  which  the  ulcerated  condition  of  the  stomach 
still  remains  because  the  ulcer-bearing  area  has  not  been  ex- 
cised are  placed  upon  a  Von  Leube  or  Lenhartz  diet.  This 
would  hold  for  acute  perforations  of  the  stomach  and  gastro- 
enterostomies. 

Von  Leube  Diet  (Modified). — For  the  first  three  days  noth- 
ing is  given  by  mouth,  but  fluid  is  supplied  by  proctoclysis 
and  a  nutritive  enema  may  be  given  three  times  daily  if  the 


162  TEXTBOOK  OF  SURGICAL  NURSING 

patient  is  asthenic.  After  a  few  days,  peptonized  milk  §  ii 
alternating  -with  vichy  3  ii  ^i^y  t)6  given  every  two  hours. 
If  this  is-  well  borne,  the  milk  is  increased  one  ounce  daily  until 
eight  ounces  are  taken.  If  the  administration  of  the  milk  is  fol- 
lowed by  no  pain,  the  amount  of  vichy  may  be  increased  to 
four  ounces.  In  about  ten  days,  thickened  soups,  such  as  puree 
of  pea,  sago,  tapioca  and  junket  are  allowed.  In  the  third  week, 
scraped  raw  beef,  very  soft  boiled  eggs,  macaroni,  puree  of 
vegetables,  and  zwieback  may  be  given.  The  patient  is  gradu- 
ally^ returned  to  a  selected  soft  diet  during  the  fourth  week. 
If  pain  appears  a  return  is  made  to  the  simpler  milk  diet. 

Lenhartz  Diet. — The  food  of  a  Lenhartz  diet  is  admin- 
istered at  hourly  intervals;  it  must  be  thoroughly  masticated 
and  eaten  very  slowly,  and,  during  the  treatment,  the  patient 
must  be  kept  in  bed.  For  the  first  week,  the  raw  eggs  which  are 
used,  are  beaten  up  whole  and  iced ;  the  milk  is  also  iced ;  gran- 
ulated sugar  is  added  to  the  eggs  on  the  third  day.  Boiled  rice, 
zwieback  and  scraped  beef  are  prepared  in  the  usual  manner. 
The  Lenhartz  diet  for  fourteen  days  is  as  follows: 

As  eggs  differ  in  size  and  weight,  take  the  total  of  eggs  for 
the  day  of  diet,  beat,  measure,  and  divide  into  seven  feedings 
and  put  into  medicine  glasses.  Keep  on  ice  and  use  as  directed, 
alternating  with  milk.  The  milk  is  kept  in  a  bowl  of  cracked 
ice,  and  the  eggs  are  beaten  up  raw  and  iced.  The  spoon  is 
kept  in  a  bowl  of  ice.  The  feedings  should  be  given  very  slowly 
and  the  patients  are  never  allowed  to  help  themselves. 

The  patient  should  be  given  small  feedings  frequently  and 
fed  by  spoon.  Salt  the  eggs  to  taste  on  the  first  and  second 
days ;  sugar  is  started  on  third  day. 

First  Day 


7  a.m. 
8 

Egg 
Milk, 

20  c.c. 

or  -/^  oz. 

9 
10 

Egg 
Milk, 

20  c.c. 

or  2/.J  oz. 

11 

12  noon 

Egg 
Milk, 

15  c.c. 

or  1/2  oz. 

1  p.m. 
2 

Egg 
Milk, 

15  c.c. 

or  %  oz. 

SURGICAL  DIETETICS  163 

First  Day — Continued. 

3  p.m.  Egg 

4  Milk,  15  c.c.  or  I/2  oz. 

5  Egg 

6  Milk,  15  c.c.  or  1/2  oz. 

7  Egg 

Total,  eggs  (raw),  2;  milk,  100  c.c.  or  8^/3  oz. 

Second  Day 

7  a.m.  Egg 

8  Milk,  35  c.c.  or  1  oz. 

9  Egg 

10  Milk,  35  c.c.  or  1  oz. 

11  Egg 

12  noon         Milk,  35  c.c.  or  1  oz. 

1  p.m.  Egg 

2  Milk,  35  c.c.  or  1  oz. 

3  Egg 

4  Milk,  35  c.c.  or  1  oz, 

5  Egg 

6  Milk,  35  c.c.  or  1  oz. 

7  Egg 

Total,  eggs  (raw),  3;  milk,  200  c.c.  or  6Y3  oz. 
Third  Day 

7  a.m.  Egg.     Sugar,  2  g-m.  or  %  oz. 

8  Milk,  50  c.c.  or  1-/^  oz. 

9  Egg.     Sugar,  3  gm.  or  %  dr. 

10  Milk,  50  c.c.  or  IV3  oz. 

11  Egg.     Sugar,  3  gm.  or  %  dr. 

12  noon         Milk,  50  c.c.  or  IY3  oz. 

1  p.m.          Egg.  Sugar,  3  gm.  or  %  dr. 

.  2  Milk,  50  e.c.  or  IV3  oz. 

3  Egg.  Sugar,  3  gm.  or  %  dr. 

4  Milk,  50  c.c.  or  IY3  oz. 

5  Egg.  Sugar,  3  gm.  or  %  dr. 

6  Milk,  50  c.c.  or  IV3  oz. 

7  Egg.  Sugar,  3  gm.  or  %  dr. 

Total,  eggs  (raw),  4;  milk,  300  c.c.  or  10  oz. ;  sugar, 
20  gm.  or  5  dr. 
Fourth  Day 

7  a.m.  Egg.     Sugar,  2  gm.  or  ^  dr. 

8  Milk,  70  c.c.  or  2V3  oz. 

9  Egg.     Sugar,  3  gm.  or  %  dr. 


164  TEXTBOOK  OF  SURGICAL  NURSING 

Fourth  Day — Conliiiucd. 

10  a.m.  Milk,  70  cc  ov  12'/.,  oz. 

11  •        Kg'g".     Sugar,  3  gin.  or  -^4  dr. 

12  noon         Milk,  G5  e.c.  or  12  oz. 

1  p.m.  Egg'.     Sugar,  3  uui.  oi-  %  dr. 

2  Milk,  05  e.c.  or  12  oz. 

3  Egg.     Sugar,  3  i^in.  or  %  (Ir- 

4  Milk,  65  e.c.  or  2  oz. 

5  Egg.     Sugar,  3  gni.  or  %  dr. 

6  Milk,  65  e.c.  or  2  oz. 

7  Egg.     Sugar,  3  gm.  or  %  dr. 

Total,   eggs    (raw),  5;  milk,  400  e.c.  or  13^^/.,  oz.; 
sugar,  20  gm.  or  5  dr. 

Fifth  Day 

7  a.m.  Egg.     Sugar,  4  gm,  or  1  dr. 

8  Milk,  80  e.c.  or  2^/3  oz. 

9  Egg.     Sugar,  4  gm.  or  1  dr. 

10  Milk,  80  e.c.  or  2^/3  oz. 

11  Egg.     Sugar,  4  g-m.  or  1  dr. 

12  noon         Milk,  80  e.c.  or  2^/3  oz. 

1  p.m.  Egg.     Sugar,  4  gm.  or  1  dr. 

2  Milk,  80  e.c.  or  2^/3  oz. 

3  Egg.     Sugar,  4  gm.  or  1  dr. 

4  Milk,  80  e.c.  or  2^/3  oz. 

5  Egg.     Sugar,  4  gm.  or  1  dr. 

6  Milk,  90  e.e.  or  3  oz. 

7  Egg.     Sugar,  4  gm.  or  1  dr. 

Total,   eggs    (raw),   0;   milk,   500   e.c.   or  16^/3   oz.; 
sugar,  30  gm.  or  1  oz. 

Sixth  Day 

7  a.m.  Egg.     Sugar,  4  gm.  or  1  dr. 

8  Milk,  100  e.c.  or  31/,  oz. 

9  Egg.     Sugar,  4  gm.  or  1  dr.     Scraped  beef,  12  gm.  or 

3  dr. 

10  Milk,  100  e.c.  or  31/3  oz. 

11  Egg.     Sugar,  4  gm.  or  1  dr. 

12  noon         Milk,  100  e.c.  or  31/3  oz. 

1  p.m.  Egg.     Sugar,  4  gm.  or  1  dr.     Scraped  beef,  12  gm.  or 

3  dr. 

2  Milk,  100  e.c.  or  31/3  oz. 

3  Egg.     Sugar,  4  g-m.  or  1  dr. 

4  Milk,  100  e.c.  or  37,,  oz. 


SURGICAL  DIETETICS  165 

Sixth  Day — Continued. 

5  p.m.  Egg.     Sugar,  4  gm.   or  1  dr.     Scraped  beef,  12  gm.  or 

3  dr. 

6  Milk,  100  c.c.  or  3^/.^  oz. 

7  Egg.     Sugar,  4  gm.  or  1  dr. 

Total,  eggs  (raw),  7;  milk,  (iOO  c.c.  or  20  oz. ;  sugar, 
30  gm.  or  1  oz.;  scrai:)ed  beef,  36  gm.  or  9  dr. 
Seventh  Day 

7  a.m.  One  soft  boiled  egg. 

8  Milk,  100  c.c.  or  31/3  oz. 

9  Egg.     Sugar,  13  gm.  or  3  dr. 

10  Milk,  100  c.c.  or  'i^/^  oz.     Scraped  beef,  23  gm.  or  6  dr. 
Boiled  rice,  33  gm.  or  1  oz. 

11  One  soft  boiled  egg. 

12  noon         Milk,  125  c.c.  or  4  oz. 

1  p.m.  Egg.     Sugar,  13  gm.  or  3  dr. 

2  Milk,  125  c.c.  or  4  oz.     Seraj^ed  beef,  23  gm.  or  6  dr. 
Boiled  rice,  33  gm.  or  1  oz. 

3  .  One  soft  boiled  egg. 

4  Milk,  125  c.c.  or  4  oz. 

5  Egg.     Sugar,  14  gm.  or  3Y3  oz. 

6  Milk,  125  c.c.  or  4  oz.     Scraped  beef,  23  gm.  or  6  dr. 
■    Boiled  rice,  33  gm.  or  1  oz. 

7  One  soft  boiled  egg. 

Total,  4  raw  eggs;  4  soft  boiled  eggs;  milk,  700  c.c. 
or  23^/3  oz. ;  sugar,  40  gm.  or  1^/3  oz. ;  scraped 
beef,  70  gm.  or  2'^/3  oz. ;  boiled  rice,  100  gm.  or 
3^/3  oz.    (served  with  beef  juice). 

Eighth  Day 

The  diet  changes  on  this  day,  re(juiring  only  4  raw  eggs  which  may 
be  divided  into  three  feedings.  The  other  4  eggs  are  to  be  soft  boiled 
and  given  as  directed  by  diet. 

7  a.m.  One  soft  boiled  egg. 

8  Milk,  135  c.c.  or  41/2  oz. 

9  Egg.     Sugar,  13  gm.  or  3  dr. 

10  Milk,  133  c.c.  or  AY2  oz.     Scraped  beef,  23  gm.  or  6  dr. 
Boiled  rice,  33  gm.  or  1  oz. 

11  One  soft  boiled  egg.    Zwieback,  10  gm.  or  2^/^  dr. 

12  noon         Milk,  133  c.c.  or  41/2  oz. 

1  p.m.  Egg.     Sugar,  13  gm.  or  3  dr. 

2  Milk,  133  c.c.  or  4^/2  oz.     Scraped  beef,  23  gm.  or  6  dr. 
Boiled  rice,  33  gm.  or  1  oz. 


166  TEXTBOOK  OF  SURGICAL  NURSING 

Eighth  Day — Conti n u c d. 

3  p.m.  One  soft  boiled  egg. 

4  ■      Milk,  133  c.c.  or  41/2  oz. 

5  Egg.     Sugar,   14  gm.   or  "dYz   ^^'-     Zwieback,   10   gin.   or 

21/2  oz. 

6  Milk,  133  c.c.  or  4V2  oz.     Scraped  beef,  24  gin.  or  6  dr. 
Boiled  rice,  33  gm.  or  1  oz. 

7  One  soft  boiled  egg. 

Total,  4  raw  eggs;  4  soft  boiled  eggs;  milk,  800  c.c. 
or   26-/3   '^^•5   seraj)ed  -beef,   70   gm.   or  2^/3   oz.; 
boiled  rice,  100  gm.  or  3^/3  oz. ;  zwieback,  20  gm. 
or  5  dr. ;  sugar,  40  gm.  or  V-/^  oz. 
Ninth  Day 

7  a.m.  One  soft  boiled  egg. 

8  Milk,  150  c.c.  or  5  oz. 

9  Egg.     Sugar,  13  gm.  or  3  dr. 

10  Milk,  150  e.e.  or  5  oz.     Scraped  beef,  23  g-m.  or  6  dr. 

Boiled  rice,  66  gm.  or  2  oz. 

11  One  soft  boiled  egg.     Zwieback,  20  gm.  or  5  dr. 

12  noon         Milk,  160  c.c.  or  5  oz. 

1  p.m.  Egg.     Sugar,  13  gin.  or  3  dr. 

2  Milk,  150  c.c.  or  5  oz.     Scraped  beef,  23  gm.  or  6  dr. 

Boiled  rice,  66  gm.  or  2  oz. 

3  One  soft  boiled  egg.     Zwieback,  20  gm.  or  5  dr. 

4  Milk,  150  c.c.  or  5  oz. 

5  Egg.     Sugar,  14  gm.  or  3%  dr. 

6  Milk,   150  c.c.   or  5  oz.     Scraped  beef,  24  gm.   or  6  dr. 

Boiled  rice,  66  gm.  or  2  oz. 

7  One  soft  boiled  egg. 

Total,  4  raw  eggs;  4  cooked  eggs;  milk,  900  c.c.  or  30 
oz.;  sugar,  40  gm.  or  1^/3  oz.;  scraped  beef,  70 
gm.  or  2^/3  oz. ;  rice,  200  gm.  or  6Y3  oz. ;  zwie- 
back, 40  gm.  or  1^/3  oz.,  or  toast,  20  gm.  or  5  dr. 
Tenth  Day 

7  a.m.  One  soft  boiled  egg. 

8  Milk,  166  c.c.  or  51/2  oz. 

9  Egg.     Sugar,  13  gm.  or  3  dr. 

10  Milk,  166  c.c.  or  5V2  oz.     Scraped  beef,  23  gm.  or  6  dr. 

Boiled  rice,  66  gm.  or  2  oz. 

11  One  soft  boiled  egg.     Zwieback,  20  gm.  or  5  dr.     Butter, 

4  gm.  or  1  dr. 

12  noon         Cooked  chopped  chicken,  25  gm.  or  6  dr.     Milk,  166  c.c. 

or  5V2  oz. 


SURGICAL  DIETETICS  167 

Tenth  Day — C ontinued. 

1  p.m.  Egg.     Sugar,  13  gm.  or  3  dr. 

2  Milk,  106  e.c.  or  5V2  oz.     Scraped  beef,  23  gm.  or  6  dr. 

Boiled  rice,  66  gm.  or  2  oz.     Butter,  4  gm.  or  1  dr. 

3  One  soft  boiled  egg.     Zwieback,  20  gm.  or  5  dr.     Butter, 

4  gm.  or  1  dr. 

4  Cooked  chopped  chicken,  25  gm.  or  6  dr. 

5  Egg.     Sugar,  14  gm.  or  3^/2  dr. 

6  Milk,  166  c.c.  or  5I/2  oz.     Scraped  beef,  24  gm.  or  6  dr. 

Boiled  rice,  67  gm.  or  2  oz.     Butter,  4  gm.  or  1  dr. 

7  One  soft  boiled  egg. 

Total,  4  raw  eggs;  4  cooked  eggs;  milk,  1000  c.c.  or 
331/g  oz.;  sugar,  40  gm.  or  1^/3  oz.;  scraped  beef, 
70  gm.  or  2^/3  oz.,  boiled  rice,  200  gm.  or  6Y3 
oz. ;  zwieback,  40  gm.  or  1^/3  oz.;  or  toast,  20  gm. 
or  5  dr.;  chicken,  50  gm.  or  IY3  oz.;  butter,  20 
gm.  or  5  dr. 

Eleventh  Day 

7  a.m.  One  soft  boiled  egg.     Milk,  250  e.e.  or  8^/3  oz. ;  zwieback, 

10  gm.  or  21/2  dr.     Butter,  4  gm.  or  1  dr. 
9  Egg.     Sugar,  13  gm.  or  3  dr.     Scraped  beef,  20  gm.  or 

5  dr.     Boiled   rice,   75   gm.   or  2^^   oz.     Zwieback,   10 
gm.  or  21/2  dr.     Butter,  6  gm.  or  I14  dr. 

11  One  soft  boiled  egg.     Milk,  250  c.c.  or  81/3  oz.     Butter, 

6  gm.  or  11/2  dr.     Zwieback,  10  gm.  or  2i/^  dr. 

1  p.m.         Egg.     Sugar,  15  gm.  or  3  dr.     Cooked  chopped  chicken, 

25  gm.  or  6  dr.     Boiled  rice,  75  gm.  or  214  oz. 
3  One  soft  boiled  egg.    Milk,  250  e.e.  or  8V3  oz.     Scraped 

beef,  20  gm.  or  5  dr.     Boiled  rice,  75  gm.  or  2I/2  oz. 
Zwieback,  10  gm.  or  21/2  dr.     Butter,  6  gm.  or  II/2  dr. 
5  Egg.     Sugar,  14  gm.  or  31/2  dr.     Cooked  chopped  chicken, 

25  gm.  or  6  dr.     Boiled  rice,  75  gm.  or  2I/2  oz.     But- 
ter, 6  gm.  or  11/2  dr. 
7  One  soft  boiled   egg.     Milk,   250  c.c.  or  8Y3  oz.     Zwie- 

back,  10   gm.   or  21/2   dr.     Butter,   6   gm.    or   II/2    dr. 
Scraped  beef,  30  gm.  or  1  oz. 

Total,  4  raw  eggs;  4  cooked  eggs;  milk,  1000  c.c.  or 
33 Y3  oz.;' butter,  40  gm.  or  IY3  oz.;  sugar,  40 
gm.  or  IY3  oz.;  scraped  beef,  70  gm.  or  2Y3  oz.; 
boiled  rice,  300  gm.  or  30  oz. ;  zwieback,  60  gm.  or 
2  oz.;  chicken,  50  gm.  or  IY3  oz. 


168  TEXTBOOK  OF  SURGICAL  NURSING 

Twelfth  Day 

7  a.iu.  One  soft  boiled  eg£i:.     Milk,  250  e.c.  or  8^/^  oz.    Zwieback, 

10  gin.  or  2V^  dr.     Butter,  4  gra.  or  1  dr. 
9  '       Egg.     Sugar,  13  gm.  or  3  dr.     Serajjed  beef,  35  gm.  or 

1   oz.     Boiled   rice,    75   gm.   or  2i/2   oz.     Zwieback,   10 
gm.  or  2^,2  dr.     Butter,  6  gm.  or  IV2  ^^'• 
11  One  soft  boiled  egg.     Milk,  250  c.c.  or  8^/3  oz.    Zwieback, 

20  gm.  or  5  dr.     Butter,  G  gm.  or  lYz  dr. 
1  p.m.  Egg.     Sugar,  13  gm.  or  3  dr.     Cooked  chopped  chicken, 

25  gm.  or  6  dr.     Boiled  rice,  75  gm.  or  2'^/2  oz.     Zwie- 
back, 10  gm.  or  2V2  dr.     Butter,  0  gm.  or  II/2  dr. 
3  One  soft  boiled  egg.     Milk,  250  e.c.  or  Sy^  oz.     Scraped 

beef,  35  gm.  or  1  oz.     Boiled  rice,  50  gm.  or  I-/3  oz. 
Zwieback,  10  gm.  or  2V2  dr.     Butter,  6  gm.  or  II/2  dr. 
5  Egg.     Sugar,  14  gm,  or  3^  o  dr.     Chopped  cooked  chicken, 

25  gm.  or  6  dr.     Boiled  rice,  75  gin.  or  2^/2  oz.     Zwie- 
back, 10  gm.  or  21/2  dr.     Butter,  6  gm.  or  IV2  dr. 
7  .         One  soft  boiled  egg.     Milk,  250  e.c.  or  8^/^  oz.    Zwieback, 

10  gm.  or  21/2  dr. 

Total,  4  raw  eggs;  4  cooked  eggs;  milk,  1000  e.c.  or 
331/3  oz. ;  sugar,  40  gra.  or  IY3  oz. ;  scraped  beef, 
70  gm.  or  2^/3  oz. ;  boiled  rice,  300  gm.  or  10  oz. ; 
zwieback,  80  gm.  or  2-/3  o^-!  chicken,  50  gm.  or 
1-/3  oz. ;  butter,  40  gm.  or  li^  oz. 
Thirteenth  Day 

7  a.m.  One  soft  boiled  egg.     Milk,  142  c.c.  or  4-/3  oz.    Zwieback, 

10  gm.  or  2^/2  dr.    Butter,  4  gra.  or  1  dr. 

9  Egg.     Sugar,  13  gm.  or  3  dr.     Milk,  142  c.c.  or  42/3  oz. 

Scraped  beef,  20  gm.  or  5  dr.     Boiled  rice,  75  gm.  or 
21/2  oz.     Zwieback,  20  gm.  or  5  dr.     Butter,  6  gm.  or 
11/2  dr. 
11  One  soft  boiled  egg.     Milk,  144  c.c.  or  5  oz.     Zwieback, 

10  gm.  or  2^  dr.     Butter,  6  gm.  or  lYo  dr. 

1  p.m.  Egg.     Sugar,  13  gin.  or  3  dr.     Milk,  142  c.c.  or  4-/3  oz. 

Cooked  chopiDed  chicken,  25  gm.  or  6  dr.  Boiled  rice, 
75  gm.  or  2I/2  oz.  Zwieback,  10  gm.  or  2V2  dr.  But- 
ter, 6  gm.  or  1/2  dr. 

3  One  soft  boiled   egg.     Milk,  144  e.c.   or   5  oz.     Scraped 

beef,  20  gm.  or  5  dr.  Boiled  rice,  75  gm.  or  2i/2  oz. 
Zwieback,  10  gm.  or  2i^  dr.     Butter,  6  gm.  or  II/2  dr. 

5  Egg.     Sugar,  14  gm.  or  3i/^  dr.     Milk,  142  c.c.  or  4^/^ 

oz.  Cooked  chopped  chicken,  25  gm.  or  6  dr.  Boiled 
rice,  75  gm.  or  21/2  oz.  Zwieback,  10  gm.  or  2i/^  dr. 
Butter,  6  gm.  or  II/2  dr. 


SURGICAL  DIETETICS  169 

Thirteenth  Day — Continued. 

7  p.m.         One  soft  boiled  egg.     Milk,  144  c.c.  or  5  oz.     Zwieback, 
10  gm.  or  2V2  dr.     Butter,  6  gm.  or  II/2  dr. 

Total,  4  raw  eggs ;  4  cooked  eggs ;  milk,  1000  c.c.  or 
33^/3  oz.;  sugar,  40  gm.  or  l^/g  oz.;  scraped  beef, 
70  gm.  or  2^/3  oz. ;  boiled  rice,  300  gm.  or  10 
oz. ;  zwieback,  80  gm.  or  2Y3  oz. ;  chicken,  50  gm. 
or  1-/3  oz.;  butter,  40  gm.  or  l^/g  oz. 
Fourteenth  Day 

7  a.m.  One    soft    boiled     egg.     Minced    chop.     Buttered    toast. 

Milk,  142  c.c.  or  42/3  oz. 
9  Boiled    rice.     Buttered    zwieback.      Custard.      Milk,    142 

c.c.  or  4-/3  oz. 
11  One  soft  boiled  egg.     Buttered  zwieback.     Junket.     Milk, 

142  c.c.  or  4-/3  oz. 
1  p.m.  Minced  chicken.     Boiled  rice.     Buttered  zwieback.     Cus- 

tard.    Milk,  142  c.c.  or  42/3  oz. 
3  One  soft  boiled  egg.     Cooked  scraped  beef.     Boiled  rice. 

Buttered  toast.    Milk,  144  c.c.  or  5  oz. 
5  Minced  chicken.     Boiled  rice.     Buttered  zwieback.     Cus- 

tard.    Milk,  142  c.c.  or  42/3  oz. 
7  One  soft  boiled  egg.     Buttered  toast.     Milk,  144  c.c.  or 

.5  oz. 

Total,  4  raw  eggs;  4  cooked  eggs;  milk,  1000  c.c.  or 
33^/3  oz.;  sugar,  4  gm.  or  1^/3  oz. ;  scraped  beef, 
70  gm.  or  2^/3  oz. ;  boiled  rice,  300  gm.  or  10  oz. ; 
zwieback,  100  gm.  or  S^/g  oz. ;  butter,  40  gm.  or 
1^/3  oz. ;  chicken,  50  gm.  or  1^/,  oz. 

Anti-Constipation  Diet. — Most  people  after  operation  are 
very  constipated.  Constipation  has  very  serious  sequela  and 
the  importance  of  impressing  upon  the  patient's  mind  the 
necessity  of  a  daily  movement  of  the  bowels  cannot  be  over- 
emphasized. There  should  be  a  regular  time  for  moving  the 
bowels,  which  should  be  observed  conscientiously.  The  best 
time  is  shortly  after  breakfast ;  the  patient  should  remain  seated 
on  the  toilet  for  at  least  five  or  ten  minutes,  and  then  if  there  is 
no  desire  to  move  the  bowels,  a  glycerine  suppository  should 
be  inserted  to  stimulate  the  movement.  Provided  there  is  no 
contraindication  to  any  of  the  coarser  vegetables,  the  patient 
should  be  placed  upon  the  anti-constipation  diet. 


170  TEXTBOOK  OF  SURGICAL  NURSING 

Diet  for  Anti-Constipation. 

Breakfast 

Any  fruit,  fresh,  cooked,  preserved,  or  dried. 

Shredded   wheat,   Thomas   uncooked   wheat   biscuit,   or   oatmeal,   or 

toasted   corn   flakes   with    cream   if   possible,    otherwise   a   small 

amount  of  milk  and  sugar  or  molasses. 
Bread. — Use  only  graham,  rye,  bran,  whole  wlieat  or  corn  bread. 
Butler,  jam,  jelly,  or  honey.     Coffee  with  cream  and  sugar. 

Liinclieon  and  Dinner 

Soup. — Any  kind  except  those  thickened  with   flour,  or  containing 

milk. 
Fish,   meat,   or   eggs   in   moderation.      Eat   as  much   of   the   fat   as 

possible. 
Vegetables. — Fresh  or  canned  in  any  quantities.     Green  salads  with 

olive  oil. 
Desserts. — Fresh  fruit  or  fruit   cooked  or  j^reserved  is  best;   also 

jellies  prepared  with  coffee,  wine  and  lemon,  etc.     Water  ices  may 

be  eaten  freely  but  only  small  amounts  of  ice  eream  may  be  taken. 

The  undererusts  of  pies  may  not  be  eaten. 

General  Directions. — Take  at  least  a  glass  of  water  beforG 
breakfast,  one  in  the  middle  of  the  day,  and  on 3  at  niglit.  In 
addition  take  as  much  water  as  maj!"  be  decired.  Tlii ;  nay  bo 
plain  water,  vichy  or  any  carbonated  water.  Evttcrmilk,  .'^our 
milk,  cider,  beer,  and  white  wine  are  allovred.  Bv.ttor  in  any 
quantity  is  permitted. 

Avoid  tea,  red  wine,  milk  and  whisky,  white  bread,  noodlc.i, 
vermicelli,  macaroni,   cake,  rice,  barlej',  potatoes,  and  (hre.:c. 

General  Riiles. — Have  a  regular  time  for  goin^  to  the  toilet. 
Take  a  daily  walk  in  the  open  air.  Practice  the  setting-up 
exercises  daily. 

Setting-up  Exercises. — 

1.  Knees  stiff;   bend  forward   and  try  to  tov.cli  £ocr  v.iLh 
fingers. 

2.  Bend  body  backward  from  hips. 

3.  Bend  body  to  the  right  and  left  from  hips. 

4.  Rotate  to  the  right  and  to  the  left  on  hips. 


SURGICAL  DIETETICS  171 

Anti-Obesity  Eoutine. — Very  often  it  is  necessary  to  reduce 
extremely  stout  individuals  before  any  operation  is  undertaken. 
Of  com\.e,  thi:j  is  difficult  to  accomplish  and  great  care  and 
judgment  should  be  exercised  because  the  patient  must  not  be 
Aveakcncd  unnecessarily.     The  general  routine  is  as  follows: 

1.  A  hot  bath  on  Monday,  Wednesday,  and  Friday  for  ten 
minutes  before  retiring. 

2.  Epsom  salts,  one  tablespoonful  in  cold  water  on  Tuesday 
morning. 

3.  Walk  at  least  one  mile  daily. 

4.  Setting-up  exercises  for  ten  minutes  each  morning  before 
breakfast. 

Anti-Obesity  Diet. 

Breakfast  Calories  Proteins 

One  orange  or  one  apple  70  1 

Coffee  with  4  tablespoonf uls  milk    20  2 

1  teaspoonf ul  sugar    20  0 

2  eggs  or  lean  meat  (about  5  x  3I/2  inches)   150  13 

Luncheon 

Cup  of  beef  tea  or  clear  soup  25  3 

Tea  with  2  tablespoonfuls  milk 20  1 

1  level  teaspoonf  ul  sugar    15  0 

2  slices  of  bread  about  4x4x^/2  inches 146  4^/^ 

1  pat  of  butter  about  1  x  1  x  V2  inches 80 

1  saiieerful  s^Dinach,  celery,  or  green  vegetable   .         5 

Lean  meat  about  5  x  3^/^  inches   300  24 

Dr.zner 

Cne  cup  of  beef  tea  or  clear  soup 25  3 

Tea  vrith  2  tablespoonfuls  of  milk 20  1 

1  te:.s^:)oonful  sugar    15  2^4 

1  fiicc^  of  bread   70  21^ 

Butter,  one  h:ilf  pat 40 

Meat  about  5x3x1/2  inches 300  24 

Entire  potato  or  2  tablespoonfuls  of  any  starchy 

vozetable  without  grease  90  2 


ToL.l   .....^ 1405  SO34 


172  TEXTBOOK  OF  SURGICAL  NURSING 

Additional  Diet  if  prescribed : 

One  quart   of  butterniilk    640  60 

American  cheese,  one  inch  cube   70  40 

Nutrient  Enemata. — As  a  rule  these  enemata  are  not  very 
sufcessful,  but  Avlien  food  is  constantly  vomited  from  the  stom- 
ach, or  M'hen  there  is  a  stenosis  of  the  cardia  of  the  stomach  or 
esophagus,  at  least  some  little  nourishment  is  received  in  this 
■vvay.  Preceding  it  a  cleansing  enema  of  about  one  pint  of 
normal  saline  solution  should  be  given.  It  is  advisable  to  use  a 
small  soft  tube  and  to  insert  it  about  25  cm.  from  the  rectum, 
for  the  higher  it  is  introduced  the  greater  is  the  absorption. 

The  food  used  in  the  enema  is  thoroughly  mixed,  then  strained 
through  cheese  cloth,  and  poured  into  the  funnel,  five  ounces 
at  a  time,  at  a  temperature  of  110°  F.  Great  care  should  be 
taken  that  no  air  is  introduced.  The  patient  must  lie  quietly 
in  bed  for  at  least  twenty  minutes  after  the  enema.  Following 
are  several  formulas  which  may  be  used : 

1.  The  whites  of  two  eggs  and  peptonized  milk,  90  c.c. 

2.  One  whole  egg,  1  gm.  of  salt,  10  c.c.  of  brandy,  90  c.c.  of 
peptonized  milk. 

3.  Boas's  formula: — 250  c.c.  milk,  yolks  of  two  eggs,  3  gm. 
table  salt,  1  tablespoonful  red  wine,  1  teaspoonful  wheat 
starch. 

Feeding  through  Fistula. — This  Ls  employed  when  an  open- 
ing has  been  made  in  the  stomach  because  of  some  benign  or 
malignant  disease  of  the  esophagus  or  cardia  of  the  stomach. 
The  food  which  is  passed  through  the  fistula  must  be  either  fluid 
or  semi-solid  and  properly  warmed. 


CHAPTER  XIII 

ANESTHESIA 

PREPARATION  OF  THE  PATIENT 

The  first  thing  to  learn  about  the  preparation  of  a  patient 
for  an  anesthetic  is  that  it  is  very  important  in  both  its  immedi- 
ate and  its  more  remote  consequences.  It  does  not  need  to  be 
explained,  of  course,  that  this  applies  to  the  various  nursing, 
treatments  such  as  the  regulation  of  diets,  medications,  etc., 
but  the  point  which  is  often  overlooked  by  the  inexperienced 
is  that  the  state  of  mind  in  which  a  patient  approaches  his 
anesthetic  will  determine  very  materially  the  way  in  which  he 
will  undergo  the  period  of  anesthesia,  and  that  this  in  turn  will 
have  a  vital  effect  upon  his  endurance  of  the  operation  and  his 
recovery,  from  the  effects  of  both  the  operation  and  the  anes- 
thetic. 

The  preparation,  therefore,  should  begin  with  the  patient's 
mind,  and  at  no  time  throughout  the  items  of  the  physical 
preparation  should  the  nurse  forget  this  important  mental  in- 
volvement in  her  work.  There  is  always  a  great  element  of 
fear  in  the  anticipation  of  taking  an  anesthetic,  of  surrender- 
ing consciousness,  and  of  submitting  to  surgery,  and  there  is 
perhaps  no  condition  which  the  anesthetist  dreads  more  in  his 
subject  than  that  of  nervous  apprehension,  for  as  a  rule  an 
agitated  or  hysterical  state  of  mind  will  reflect  itself  in  the 
physical  reactions  to  the  anesthetic  and  will  nearly  always  per- 
sist throughout  the  operation  and  the  recovery  from  the  anes- 
thetic. The  muscles  of  the  body  in  such  subjects  will  be  tense 
and  this  will  entail  shallow  and  irregular  respirations  and 
consequently  slow  and  irregular  absorption  of  the  anesthetic. 
Crying  will  do  the  same  and  in  addition  will  cause  detrimental 
obstruction  of  the  air  passages  by  tears,  mucus,  and  conges- 
tion.   Conscious  resistance  by  these  patients  will  pass  over  into 

173 


174  TEXTBOOK  OF  SURGICAL  NURSING 

unconscious  struggling  as  the  anesthesia  develops,  and  Avill  pro- 
long and  complicate  it  in  numerous  Avays.  And  finally,  all  tlieic 
irregularities  will  use  up  valuable  vitality  and  preclude  tlio 
best  anesthesia  and  recovery.  This  state  of  alrairs  the  nvirse 
can  j)revent  entirely  in  some  cases  and  to  a  great  degree  in  mo:t 
cases  by  judieious  word  and  deed  as  she  goes  about  the  prepara- 
tion. This  merely  means  that  her  general  attitude  will  be  re- 
assuring and  encouraging,  and  that  she  will  avoid  as  far  a^ 
possible  all  reminders  of  the  event  for  which  tho  Ij  preparing. 
Such  conduct  has,  of  course,  been  dinned  ir.to  every  nurss'.i 
ears  continuously  ever  since  she  entered  the  ho.';;:ital  an  the 
only  kind  which  ever  befits  a  nurse,  but  t-he  mu.Gt  practice 
it  in  this  case  Avith  the  utmost  degree  of  refinement. 

With  this  lesson  well  in  hand  the  hodily  prepar2iiD:i  ol  the 
patient  may  be  taken  up.  There  Avill  be  specific  orders  by  tho 
surgeon,  and  these  Avill  vary  in  detail;  and  there  Avill  also  be 
variations  depending  upon  the  anesthetic  to  be  given  and  the 
nature  of  the  operation.  Nevertheless,  though  Ave  can  cover 
this  ground  in  only  a  someAvhat  general  Avay  we  shall  enumerate 
the  probable  steps  as  f oIIoavs  : 

1.  A  cathartic  will  he  administered  twelve  or  more  hours  be- 
fore the  operation. 

2.  Six  hours  or  more  in  advance  food  will  he  prohihitcd  or 
perhaps  restricted  to  fluids  till  tAA'o  or  three  hours  before  the 
appointed  time  for  the  operation,  and  then  nothing  Avill  be 
administered  by  mouth.  It  is  obligatory  that  several  hours  of 
starA^ation  immediately  precede  an  anesthetic  because  anything 
in  the  stomach,  even  water,  is  likely  to  cause  A^omiting  Avhen 
the  anesthetic  begins  to  take  effect,  and  this,  besides  being 
annoying,  may  have  serious  asphj'xial  results.  In  some  cases  the 
question  of  harmful  prostration  from  lack  of  food  may  override 
the  danger  of  its  presence  in  the  stomach,  but  care  must  be 
exercised  in  this  event  to  give  foods  which  the  stomach  Avill  dis- 
pose of  most  rapidly  such  as  broths,  tea  or  coffee,  etc. ;  and 
milk  should  be  especially  avoided  for  this  reason,  even  :n  the  tea 
and  coffee. 

3.  The  operative  field  may  be  prepared  at  any  time,  but  this 
Avill  usually  be  determined  by  order  and  by  circumstances,  and 


ANESTHESIA  175 

suggestions  pertaining  to  specific  cases  have  been  pointed  out 
in  their  proper  connections  in  Chapters  IV  to  XI. 

4,  Several  hours  in  advance  one  or  more  cleansing  enemas  will 
be  given.  This  part  of  the  preparation  must  be  done  with  con- 
siderable caution  because  it  must  be  remembered  that  the  pa- 
tient has  probably  been  subjected  to  vigorous  catharsis  which 
may  have  been  exhausting,  that  the  tonic  effect  of  food  has  been 
denied,  and  that  in  any  case  an  enema  is  liable  to  be  prostrating. 
Norvou-i  patients,  and  those  in  a  state  of  reduced  general  vitality 
may  entirely  collapse  under  the  administration  of  the  enema 
at  tli-ij  time  if  care  is  not  exercised.  Plenty  of  time  should 
be  reserved  for  this  treatment  and  all  suggestion  of  haste  should 
be   avoided. 

5.  In  cases  of  intestinal  obstruction,  other  cases  where  the 
Etoniaih  is  probably  not  empty,  or  where  an  operation  is  to 
be  pcrrormed  upon  the  stomach  a  lavage  may  be  given.  This 
U  another  treatment  which  calls  for  extreme  calmness  because 
it  is  alv/ays  a  trying  and  exhausting  ordeal  for  the  patient  and 
those  needing  it  will  usually  be  in  poor  condition. 

G.  Immedicitely  before  the  anesthetic  is  administered  the 
hladdcr  miict  he  emptied  and  by  catheterization  if  necessary. 

7.  The  patient  i-^  clad  in  loose,  simple  clothing  and  plenty  of 
it,  acccrdir.g  to  the  season.  As  a  rule,  a  nightgown  reinforced 
over  the  chest  with  a  piece  of  flannel,  loosely-fitting  stockings, 
and  a  cuitablo  number  of  blankets  will  comprise  the  wearing 
apparel. 

8.  False  tecih,  including  detachable  bridgework,  will  be  re- 
moved and  carefully  laid  away. 

9.  All  jewelry  is  removed  and  safely  cared  for  also.  In  cases 
where  there  may  be  prejudice  on  the  part  of  the  patient  against 
removing  some  article  of  jewelry,  such  as  a  ring,  it  should  be 
secured  against  loss  by  anchoring  in  place  with  a  piece  of  tape  or 
bandage. 

CARE  OF  PATIENT  DURING  ANESTHESIA 

The  policy  of  calmness  and  reassurance  which  you  adopted 
before  beginning  the  preparation  must  be  observed  with  re- 
doubled  effort  when   the   administration    of  the   anesthetic   is 


176  TEXTBOOK  OF  SURGICAL  NURSING 

begun,  because,  as  pointed  out  above,  the  mental  attitude  of  the 
patient  will  determine  his  behavior  in  general  throughout  his 
anesthesia.  Absolute  quiet  in  the  room  will  be  necessary  for 
the  best  results,  and  talking  or  Avhispering,  especially  after 
the  administration  of  the  anesthetic  has  been  begun,  are  par- 
ticularly objectionable  because  the  sense  of  hearing  is  one  of  the 
last  to  be  anesthetized  'and  as  it  often  functions  capriciously 
at  this  time  patients  may  get  undesirable  impressions  from 
what  is  said.  Furthermore,  conversation  often  leads  partially 
anesthetized  patients  to  make  efforts  to  participate  in  it  and 
this  will  delay  the  anesthesia  and  aggravate  the  excitement. 
Also,  too  great  caution  cannot  be  taken  in  deciding  when  the 
sense  of  hearing  has  been  entirely  overcome  and  when  it  w'ill 
be  safe  to  indulge  in  professional  discussion  of  the  patient's 
condition  which  it  might  not  be  wise  for  him  to  hear. 

There  will  always  be  some  degree  of  struggling,  sometimes 
voluntary  and  nearly  always  involuntary,  during  the  induction 
of  the  anesthesia,  particularly  in  the  case  of  ether,  and  the 
nurse  will  usually  be  expected  to  do  guard  duty  against  this. 
The  arms  and  legs  will  be  her  chief  concern,  for  though  some- 
times a  strong  patient  will  endeavor  to  sit  up  and  even  thrust 
himself  from  the  table,  if  the  arms  and  legs  are  kept  in  place 
he  is  helpless  further.  It  is  sometimes  the  custom  to  restrain 
the  legs  by  binding  them  to  the  table  with  a  strong  strap  passed 
just  above  the  knees.  With  a  strong,  healthy  patient,  which  is 
the  type  most  likely  to  cause  trouble,  this  precaution  may  be 
necessary,  especially  if  there  are  not  enough  assistants  available 
to  control  him,  for  one  assistant  cannot  manage  such  a  subject ; 
but  this  practice  will  be  very  exciting  to  some  patients  and 
should  not  be  adopted  unless  absolutely  necessary.  For  these 
excitable  patients  a  good  plan  will  be  to  have  this  strap  ready 
and  to  defer  the  adjustment  of  it  till  a  degree  of  unconscious- 
ness has  been  attained;  or,  some  subjects  will  not  be  alarmed 
by  this  restraint  if  it  is  explained  that  you  are  applying  it 
to  prevent  them  from  rolling  from  the  narrow  table  after  they 
have  gone  to  sleep.  In  fact,  this  apology  for  the  strap,  if 
sincerely  made,  will  sometimes  comfort  a  nervous  patient  and 


ANESTHESIA  177 

give  him  a  sense  of  security,  though  one  always  runs  a  risk 
when  undertaking  this  plan. 

In  some  institutions  it  is  the  practice  to  bind  the  arms,  shoul- 
ders, and  legs  to  the  table  with  a  few  turns  of  a  strong  bandage, 
and  the  anesthetist  is  then  able  to  proceed  alone,  but  it  will 
be  a  rare  patient  who  will  not  suffer  more  or  less  under  such 
treatment  and  it  seems  that  urgent  necessity  is  the  only  justifi- 
cation for  it. 

Whatever  plan  may  be  adopted  for  guarding  the  legs,  the 
attendant  nurse's  duty  will  be  to  care  for  the  hands.  Most 
patients  are  reassured  by  having  their  hands  supported  gently 
by  another  person  at  this  time  because  they  realize,  of  course, 
that  they  will  soon  be  unconscious,  and  many  have  expressed 
apprehension  of  danger  befalling  their  hands.  AVith  strong 
patients  who  may  be  expected  to  be  exceptionally  hard  to  con- 
trol, it  will  be  best  to  ask  them  to  place  their  hands  comfortably 
upon  the  table  at  their  sides  and  to  turn  the  palms  down- 
ward; the  nurse  can  place  a  hand  gently  upon  each  of  his 
wrists  (standing  with  face  toward  the  anesthetist)  and  thus 
be  prepared  for  the  worst,  for  pressure  upon  the  wrists  can 
prevent,  the  patient  from  turning  his  palms  from  the  table 
and  unless  he  can  turn  his  hand  he  cannot  arise.  This  will 
be  an  unnecessary  precaution,  however,  for  the  average  pa- 
tient, and  the  nurse's  rule  should  be  to  advise  him  to  put  his 
hands  where  they  are  most  comfortable  and  then,  in  a  natural 
way,  to  place  her  own  hands  upon  his  wrists  or  forearms  in 
such  a  way  as  to  be  prepared  to  foil  any  sudden  attempt  upon 
his  part  to  do  the  instinctive  thing  of  grabbing  the  inhaler. 

The  nurse  responsible  for  the  hands  should  form  the  Jidbit 
of  following  the  pulse.  Anesthetists  will  do  this  for  themselves 
but  there  are  times  when  they  are  so  entirelj^  occupied  otherwise 
that  many  of  them  will  be  grateful  for  this  assistance.  In  per- 
forming this  service  the  nurse  must  know  what  variations  to 
expect  under  the  several  anesthetics,  and  these  we  shall  in- 
dicate on  pages  178-180  where  we  discuss  some  of  the  reactions 
of  patients  to  the  more  common  anesthetics. 

Care  should  always  be  taken  not  to  hold  the  hand  of  a  pa- 
tient in  such  a  w^ay  that  he  may  grip  it,  for  a  strong  one  may 


178  TEXTBOOK  OF  SURGICAL  NURSING 

entirely  overcome  a  nurse  in  this  way  when  in  the  stage  of 
excitement  and  he  may  even  injure  her. 

The  foregoing  comments  will  apply  in  a  general  way  to 
subjects  of  all  anesthesia,  but  as  your  specific  troubles  and 
duties  will  depend  somewhat  upon  which  of  the  several  anes- 
thetics is  used  we  shall  take  up  separately  each  one  of  the 
four  more  common  ones:  nitrous  oxide,  ether,  chloroform,  and 
ethyl  chloride,  and  point  out  briefly  the  usual  behavior  of 
patients  under  them  and  the  corresponding  nursing  care. 

Nitrous  Oxide. — The  induction  period  of  this  anesthetic  is 
very  short,  lasting  only  a  few  seconds  and  there  will  be  little 
or  no  struggling,  so  the  nurse's  duties  will  not  extend  much 
bej'ond  assisting  the  anesthetist  in  Iteeping  the  patient  com- 
posed so  that  he  will  breathe  deeply  and  regularly.  The  gen- 
eral precautions  against  excitability  outlined  above,  however, 
should  always  be  taken  as  occasionally  they  will  be  helpful. 

With  nitrous  oxide  tlie  pulse  should  not  show  much  change, 
but  should  be  regular,  full  and  quiet. 

Ether. — This  anesthetic  calls  for  all  the  precautions  men- 
tioned above  because  its  induction  period  is  relatively  long, 
the  anesthetic  is  comparatively  disagreeable  to  take,  there  is 
almost  always  a  period  of  excitement  of  greater  or  less  dura- 
tion and  severity,  and  there  are  numerous  respiratory  and  other 
irregularities  which  may  arise  and  call  for  a  helping  hand  from 
the  nurse. 

The  anesthetist  will,  of  course,  guide  the  nurse's  general 
course  of  action,  but  unless  otherwise  instructed  she  will  make 
no  mistake  by  following  the  more  moderate  course  we  have 
already  advised.  On  the  subject  of  restraint  during  the  stage  of 
excitement  in  the  induction  of  ether  anesthesia  anesthetists  will 
disagree.  Some  will  prefer  absolute  resistance  from  the  begin- 
ning to  all  efforts  on  the  part  of  the  patient,  especially  with 
his  hands,  and  others  will  act  upon  the  belief  that  early  resist- 
ance to  these  efforts  only  aggravates  them  and  will  therefore  ad- 
vise permitting  any  activity  that  does  not  displace  the  inhaler 
or  allow  the  patient  to  harm  himself  or  the  attendants.  Per- 
sonally, we  have  been  entirely  converted  to  this  practice  and 
are  therefore  inclined  to  advise  the  nurse  to  adopt  it  where  she 


ANESTHESIA  179 

is  not  otherwise  directed  by  the  anesthetist,  but  she  must  )k;  very 
Gure  beforehand  that  she  is  prepared  to  carry  it  out  success- 
fully, and  must  remember  that  even  though  the  plan  may  suc- 
ceed at  first,  some  cases  will  later  compel  her  to  abandon  it  for 
the  sterner  measures. 

With  ether  one  expects  the  pulse  to  increase  more  or  less  in 
force  and  frequency,  but  extreme  or  sudden  increase  in  fre- 
quency and  other  abnormal  developments  in  the  pulse  will  be 
matters  of  concern. 

Chloroform. — The  induction  of  chloroform  anesthesia  is 
usually  less  eventful  from  the  nurse's  standpoint  than  that  of 
ether,  that  is,  cases  of  extreme  excitement  will  not  be  so  numer- 
ous; but  they  will  occur  and  must  therefore  be  kept  in  mind. 
There  is  one  important  difference  between  the  two  anesthetics 
which  the  nurse  should  note,  and  that  is  that  ether  is,  in  gen- 
eral, stimulating  to  the  action  of  the  heart  in  the  early  period  of 
its  administration  while  chloroform  is  depressing.  For  this  rea- 
son patients  to  whom  chloroform  is  being  administered  should 
not  be  allowed  the  extreme  activity  during  the  stage  of  excite- 
ment which  we  have  advised  for  those  receiving  ether.  The 
anesthetist  will  control  this,  but  we  owe  it  to  the  nurse  here  to 
emphasize  the  fact  that  the  method  w^e  recommended  so  highly 
for  ether  patients  must  be  confined  to  them. 

The  pulse  of  the  chloroform  patient  is  of  comparative  impor- 
tance. We  have  just  remarked  that  chloroform  depresses  the 
heart,  and  so  it  does,  but  the  nurse  watching  the  pulse  will 
notice  that  in  the  very  beginning  of  the  administration  there 
may  be  a  slight  quickening  of  the  pulse  and  a  noticeable  in- 
crease in  its  force.  Very  soon,  however,  there  will  be  a  gradual 
decrease  of  both  which  will  probably  extend  below  the  level  you 
noticed  before  the  anesthetic  was  started.  Extremes  in  either 
direction  are,  of  course,  danger  signals. 

Ethyl  Chloride. — Ethyl  chloride  is  not  in  general  use  for  pro- 
longed anesthesia,  but  it  is  popular  in  some  communities  for 
short  operations  and  dressings  which  require  onlj^  a  few  mo- 
ments. We  mention  it  here  since  its  administration  will  usually 
require  the  attendance  of  a  nurse  throughout  because  entire 
relaxation  is  rarely  attained  and  restraint  of  hands  or  the  part 


180  TEXTBOOK  OF  SURGICAL  NURSING 

operated  upon  will  usually  be  necessary.  Induetion,  entire 
anesthesia,  and  recovery  will  all  take  place  within  a  few  mo- 
ments, and  as  vomiting  often  occurs  very  soon  after  the  with- 
drawal of  the  inhaler,  the  nurse  should  be  prepared  for  this 
from  the  beginning. 

With  ethyl  chloride  the  pulse  should  not  show  much  change, 
as  a  rule,  except  perhaps  a  slight  decrease  of  frequency  and 
force. 


During  the  operation  the  anesthetist  will  be  responsible  for 
observing  the  general  condition  of  the  patient,  but  the  operat-' 
ing  room  nurse  also  should  make  it  a  rule  to  remember  the  pa- 
tient's condition  and  to  be  prepared  to  supply  warm  blankets, 
hot  water  bottles,  hypodermics,  etc.,  at  any  time.  The  tempera- 
ture of  the  room  is  also  the  nurse's  responsibility,  and  she  should 
remember  that  maintenance  of  the  standard  temperature  (75°- 
76°  F.)  and  the  exclusion  of  draughts  have  a  direct  influence 
in  conserving  the  patient's  well-being. 

AFTER  CARE 

After  the  operation  the  nurse  will  usually  be  left  entirely 
responsible  for  the  preparation  of  the  patient  for  the  journey  to 
his  bed,  and  she  will  see  that  he  is  well  wrapped  in  blankets. 
During  anesthesia,  especially  with  ether,  there  may  be  con- 
siderable perspiration,  and  as  the  outer  hallways  through  which 
the  patient  is  carried  will  doubtless  be  cooler  than  the  operat- 
ing room  and  well  supplied  with  draughts  it  will  be  very  easy 
for  him  to  become  suddenly  chilled  and  thus  to  contract  bron- 
chitis or  pneumonia.  Also,  ether  patients  have  been  given  a 
predisposition  to  these  two  complications  by  the  irritant  effect 
of  ether  upon  the  air  passages.  In  any  other  case,  no  mat- 
ter what  the  anesthetic  has  been,  it  must  be  remembered  that  the 
patient's  vitality  has  been  lowered  by  both  it  and  the  operation 
itself  and  that  he  must  be  as  well  fortified  as  possible  against 
the  effects  of  sudden  change  of  temperature. 

Special  care  must  be  taken  also  in  handling  an  anesthetized 
patient,  for  violent  or  sudden  change  of  position  may  seriously 


ANESTHESIA 


181 


interfere  with  cardiac  or  respiratory  action  either  directly  by 
overtaxation  or  indirectly  by  inducing  vomiting  and  conse- 
quent choking,  etc.  Often,  when  ether  or  chloroform  anes- 
thesia has  been  profound,  the  patient  may  be  transferred  to 
his  bed  without  arousing  him  to  any  degree  if  he  is  handled 


Fig.  18. — An  Easy  and  Safe  Method  of  Lifting  a  Helpless  Patient. 
The  two  nurses  at  the  sides  of  the  table  are  grasping  a  piece  of  heavy 
canvas,  about  1  yard  long  and  %  yard  wide,  which  lies  across  the  table 
under  the  patient's  hips. 

gently  and  quietly.     A  good  method  of  lifting  patients  care- 
fully and  easily  is  illustrated  in  Fig.  18. 

The  bed  should  have  been  previously  warmed  with  hot  water 
bottles,  a  warm  blanket  should  be  placed  directly  underneath 
the  patient  and  plenty  of  warm  ones  over  him — that  is,  there 
are  no  intervening  sheets.  His  bedroom  should  be  well  heated, 
draughts  avoided,  and  the  temperature  of  his  body,  particularly 


182  TEXTBOOK  OF  SURGICAL  NURSING 

the  hands  and  feet,  observed  from  time  to  time  by  feeling  them. 
In  warm  weather,  or  when  the  patient  is  in  good  general  health 
and  the  anesthesia  has  been  slight  or  short  (as  in  short  admin- 
istrations of  nitrous  oxide  or  ethyl  chloride)  the  blankets  and 
some  of  the  other  precautionary  measures  may  not  be  necessary, 
but  the  patient  should,  of  course,  be  given  the  benefit  of  any 
doubt. 

Though  events  of  recovery  will  depend  somewhat  upon  the 
temperament  and  physical  condition  of  the  patient,  there  is 
a  general  course  which  may  be  expected  for  each  of  the  anes- 
thetics and  certain  accidents  and  complications  which  are  pe- 
culiar to  each.  We  shall,  therefore,  discuss  separately  the  re- 
covery to  be  expected  from  each  of  the  four  anesthetics.  It 
must  be  remembered,  however,  in  all  cases  that  the  nature* 
of  the  operation  modifies  recovery  to  a  greater  or  lesser  de- 
gree, but  your  study  of  shock,  hemorrhage,  and  other  operative 
and  post-operative  complications  will  teach  you  to  make  the 
necessary  differentiations. 

Nitrous  Oxide. — Patients  who  have  had  this  gas  will  recover 
within  a  very  few  minutes,  as  a  rule,  though  the  time  will 
often  be  prolonged  by  hysterical  outbursts  of  laughing,  crying, 
etc.  Nausea  and  vomiting  sometimes  occur,  but  they  are  in- 
frequent. Oftenest  a  patient  will  shows  signs  of  lassitude 
and  may  sleep  for  a  considerable  time.  Headache  is  not  uncom- 
mon and  may  sometimes  be  very  persistent.  The  pulse  and  res- 
pirations of  these  patients  should  always  be  watched  closely  for 
some  time,  but  as  a  rule  recovery  will  be  uneventful  in  these 
respects. 

Nitrous  oxide  subjects  will  usually  be  able  to  take  nourish- 
ment comparatively  soon  after  recovery,  but  the  surgeon 's  orders 
will  determine  the  nurse's  course  in  this  respect,  as  there  will 
often  be  surgical  reasons  of  which  the  nurse  may  not  know 
which  will  control  administrations  by  mouth.  Comments  on 
page  188  on  the  administration  of  water  to  ether  patients  will 
apply  in  general  to  nitrous  oxide  subjects,  and  detailed  in- 
structions as  to  diets  in  all  cases  are  given  under  the  subject 
of  surgical  diets  in  Chapter  XII,  ai^d  in  the  discussions  of  the 
various  operative  conditions  in  Chapters  IV-XI. 


ANESTHESIA 


183 


Ether. — Recovery  from  this  anesthetic  calls  for  careful  nurs- 
ing, and  patients  should  not  be  left  alone  for  one  moment  until 
consciourjness  is  entirely  established,  for  whatever  aid  they  may 
need  during  this  time  must  be  given  promptly. 

Pro\i-ion  should  be  made  early  for  the  restraint  of  violence 
during  resovery,  for  all  the  efforts  incident  to  the  stage  of  ex- 
citaliJty  in  the  induction  of  the  anesthesia  may  be  repeated 
during  recovery.     The  favorite  attempt  of  these  patients  is  to 


Fig.  19. — Restraining  Sheet  for  Patients  Eecovering  from  an  An- 
esthetic. Strong  safety  pins  may  keep  this  in  place  on  tlie  bed  frame;  if 
the  bar  to  which  it  is  attached  is  not  cylindrical,  friction  will  hold  a  tightly 
drawn  and  well  tucked  in  sheet;  or,  the  sheet  may  be  passed  entirely 
around  the  bed  springs  and  the  ends  fastened  together  underneath. 

get  out  of  bed,  and  if  there  are  not  enough  assistants  to  control 
them  throughout  the  period  of  this  tendency  a  restraining 
sheet  should  be  fastened  across  the  bed  just  over  the  knees  (Fig. 
19).  This  will  be  of  enough  assistance,  as  a  rule,  so  that  one 
nurse  can  master  the  situation. 

The  respirations  should  be  watched  closely,  for  there  are  many 
respiratory  complications  which  may  arise  before  consciousness 
is  regained.  Regularly,  the  patient  recovering  from  ether  will 
breathe  less  deeply  and  vigorously  than  normally  because, 
though  ether  acts  as  a  stimulant  early  in  its  administration, 


18i  TEXTBOOK  OF  SURGICAL  NURSING 

it  eventually  tends  to  depress  the  respiratory  nerve  center. 
The.  color  of  the  face,  particularly  of  the  ears  and  lips,  will  be 
a  good  guide  as  to  whether  or  not  he  is  inhaling  sufficient  oxygen 
if  it  is  not  convenient  to  observe  his  chest  motion.  In  this 
connection  the  nurse  should  remember  that  sedatives,  especially 
morphine,  if  given  recently,  will  probably  have  contributed  to 
the  depression  and  she  will  make  allowance  on  that  basis  for 
abnormally  slow  or  shallow  respirations,  but  she  should  not  be 
too  slow  to  be  alarmed  by  respiratory  depression  after  an  anes- 
thetic. In  cases  of  extreme  or  sudden  depression,  while  wait- 
ing for  help,  vigorous  rubbing  of  the  lips  and  face  with  a 
coarse  towel  may  revive  the  patient  somewhat,  and  of  course  the 
nurse  is  always  prepared  to  give  artificial  respiration  in  cases 
of  emergency.  However,  if  the  color  and  pulse  are  good  and 
the  patient  is  breathing  unobstructedly  the  best  treatment  is 
to  leave  him  alone,  for  many  will  pass  unconsciously  from  their 
anesthesia  into  a  sound  sleep  from  which  they  will  awaken  in 
an  hour  or  two  fully  recovered  and  more  comfortable  for  thus 
having  passed  away  time  which  would  otherwise  have  been 
very  unpleasant.  This  last  remark  has  been  inspired  by  obser- 
vation of  occasional  instances  in  which  concern  has  been  felt 
for  the  patient  who  quietly  "slept  off"  his  anesthetic,  and  he  has 
been  aroused  with  no  other  effect  than  to  bring  him  into  earlier 
consciousness  of  his  troubles  than  necessary. 

Other  respiratory  complications  may  arise  early  through 
occlusion  of  the  pharynx  by  a  swollen  or  flabby  tongue  or  by 
accumulation  of  mucus  or  vomitus.  This  can  usually  be  avoided 
by  keeping  the  patient's  head  turned  to  one  side  during  re- 
covery, or,  if  possible,  by  turning  his  entire  body  toward  one 
side,  both  of  which  measures  allow  any  fluid  to  run  out  of  the 
mouth  and  also  tend  to  throw  the  tongue  and  jaw  forward  and 
away  from  the  posterior  wall  of  the  pharynx.  In  cases  of  per- 
sistent tendency  of  the  tongue  to  occlude  the  throat  the  simple 
pushing  forward  of  the  jaw  may  overcome  the  difficulty  as  this 
carries  the  tongue  forward  also.  This  is  often  hard  for  the 
young  nurse  to  learn  to  do  properly,  but  if  she  will  first  make 
sure  that  the  teeth  are  not  locked  together  and  will  then  thrust 
the  lower  teeth  in  front  of  the  upper  ones,  or  as  nearly  so  as 


ANESTHESIA  185 

possible,  she  will  accomplish  all  that  she  can  by  this  measure. 
Sometimes,  however,  it  may  be  necessary  to  reach  into  the  mouth 
with  a  pair  of  tongue  forceps  (Fig.  20),  or  the  fingers  covered 
with  a  towel  or  piece  of  gauze,  and  pull  the  tongue  forward  and 
swab  out  the  mucus  with  a  sponge  on  a  holder.  For  this  it 
will  be  necessary  to  hold  the  mouth  open  with  a  mouth  gag  of 
some  sort  (Fig.  21)  so  as  to  prevent  biting  of  the  fingers,  the 
tongue,  or  the  sponge  forceps.  Occasionally  a  spasm  of  the  jaw 
will  accompany  this  condition  and  the  patient  will  become  very 


Fig.  20. — Suitable  Instruments  for  Grasping  the  Tongue.  The  two 
having  locks  are  the  more  useful  because  they  answer  also  as  sponge  holders 
for  swabbing  out  the  throat,  but  when  used  for  grasping  the  tongue  care 
must  be  taken  not  to  lock  them  so  tightly  as  to  crush  it. 

cyanotic.  This  calls  for  vigorous  and  quick  action  in  prying 
the  mouth  open  wdth  a  mouth  gag  and  relieving  the  obstruc- 
tion as  just  described.  In  doing  this  great  care  must  be  taken, 
of  course,  not  to  injure  the  teeth. 

Nausea  and  vomiiting  will  occur  in  an  average  of  50  per  cent, 
of  the  ether  cases.  Some  anesthetists  show  lower  percentages 
than  this,  but  half  the  cases  will  be  a  fair  number  to  count 
upon.  This  should  not  persist  for  more  than  a  few  hours,  though 
patients  naturally  subject  to  digestive  disorders  may  be  thus 
annoyed  much  longer.  Special  care  must  be  exercised  with  the 
patient  when  vomiting  as  there  is  always  danger  of  his  inhaling 


186  TEXTBOOK  OF  SURGICAL  NURSING 

the  vomitus  and  becomiug  asphyxiated  by  it ;  and  it  is  also  pos- 
sible that  inhaled  vomitus  is  responsible  for  some  cases  of 
"ether  pneumonia."  Also,  his  eyes  must  be  shielded  from  the 
vomitus  as  they  may  be  considerably  irritated  by  it  and  de- 
velop a  troublesome  and  painful  case  of  conjunctivitis.  AVhen 
consciousness  has  been  recovered  to  some  degree  the  coughing 
reflex  will  function  and  the  patient  will  be  able  to  save  himself 
from  tlie  asphyxial  danger  by  coughing,  but  in  any  case  his 
head  should  be  held  to  one  side  while  vomiting  and  the  mouth 


Fig.  21. — Mouth  Gags.  A,  a  simple  wooden  wedge  which  is  very  safe 
and  very  serviceable  for  prying  the  teeth  apart,  as  well  as  for  holding  the 
mouth  open  temporarily  for  swabbing,  pulling  the  tongue  forward,  etc. ; 
B,  metal  gag  which  can  be  inserted  only  after  the  teeth  have  been  well 
parted,  but  which  is  self -retaining  when  well  placed. 

swabbed  clean  if  necessary.  The  character  of  the  vomitus 
should  always  be  noted.  In  ether  cases  there  is  likely  to  be 
much  mucus,  as  ether  stimulates  all  secretions  more  than  the 
other  anesthetics;  and  there  will  be  indications  of  bile  some- 
times, and  of  stomach  secretions.  If  blood  is  present  it  will  be 
a  matter  of  special  concern.  However,  if  the  operation  has 
been  upon  some  part  of  the  mouth,  nose,  throat,  or  stomach,  it 
must  be  expected  that  old  blood  ("coffee  grounds")  which  has 
been  spilled  or  swallowed  will  be  vomited.  Bright  red  blood 
is  alarming  also,  but  a  bitten  tongue  or  a  loosened  tooth  may 
be  the  contributing  agent  of  this.    Any  case  of  unusual  vomitus, 


ANESTHESIA  187 

however,  should  be  reported  to  the  surgeon  as  it  will  usually 
call  for  investigation  by  him. 

The  pulse,  of  course,  is  watched  closely.  That,  too,  will  be 
somewhat  depressed,  at  least  for  a  short  time  after  the  patient's 
return  to  bed,  but  within  an  hour  or  so  it  should  show  signs 
of  recuperation. 

There  are  several  odd  manifestations  which  may  accompany 
recovery  from  ether,  such  as  tremor,  hiccough,  etc.,  but  they  are 
usually  transitory  and  are  not  seriously  significant  unless  they 
persist  unduly.  It  is  very  likely  that  the  patient  who  has  mani- 
fested the  tremor  during  the  induction  of  his  anesthesia  will  do 
so  again  when  he  recovers,  but  the  nurse  must  not  make  the 
mistake  of  overlooking  a  real  chill  in  these  patients  because 
the  two  conditions  are  easily  confounded  and  a  chill,  as  every 
nurse  knows,  is  not  to  be  taken  lightly.  Likewise,  persistent 
hiccough  should  be  regarded  seriously  because,  aside  from  be- 
ing very  distressing  to  the  patient,  it  may  signify  something 
deeper  than  a  mere  irregularity  of  recovery  of  consciousness. 

Pulmonary  edema  is  another  complication  of  ether  anes- 
thesia, though  it  is  an  infrequent  one.  The  nurse  has  doubt- 
less learned  elsewhere  the  symptoms  of  edema  of  the  lungs  and 
will  at  once  recognize  the  unmistakable  sound  caused  by  the 
great  quantity  of  mucus  which  has  accumulated  in  the  lungs 
and  is  being  "washed"  back  and  forth  with  respirations.  A 
collection  of  thick  mucus  in  the  throat  will  sometimes  cause  a 
similar  sound  and  even  a  degree  of  the  cyanosis  so  prominent 
in  edema,  but  swabbing  of  the  throat  and  observations  of  the 
patient's  general  condition  will  quickly  tell  the  nurse  whether 
or  not  to  be  alarmed. 

Another  complication  to  be  feared  and  guarded  against  is 
''ether  pneumonia."  It  is  not  frequent,  but  the  nurse  must 
always  bear  it  in  mind.  General  nursing  training  will  have 
taught  the  nurse  the  warning  signs  and  symptoms  of  pneu- 
monia, so  we  shall  not  take  space  for  them  here. 

Some  authorities  attribute  one  or  two  kidney  disorders  to 
ether,  chiefly  that  of  albuminuria  and  sometimes  suppression. 
Urinalysis  will  show  that  albuminuria  often  does  arise  after 
anesthesia;  but  whether  it  is  caused  by  the  anesthetic  or  by 


188  TEXTBOOK  OF  SURGICAL  NURSING 

something  else  "svill  not  eoneern  us  here  as  its  treatment,  if 
there  is  any,  -will  be  by  prescription  only.  Suppression,  of 
course,  "would  be  a  serious  condition  but  it  is  a  nursing  prob- 
lem here  only  in  so  far  as  the  nurse  ^vill  be  responsible  for 
reporting  as  to  whether  or  not  evacuations  of  the  bladder  occur 
normall}'.  This  subject  is  entered  into  more  fully  in  Chapter 
III,  page  32,  under  post-operative  complications. 

The  voiding  of  urine  is  always  a  matter  of  attention  after 
anesthesia  and  if  it  does  not  occur  normally,  or  nearly  so,  it 
must  be  regarded  with  concern.  This  may  be  due  to  suppres- 
sion, which  may  or  may  not  have  reference  to  the  anesthetic ; 
but  it  will  be  very  much  more  likely  to  be  due  to  some  deranging 
effect  of  the  anesthetic  or  the  operation  upon  the  nerve-control 
of  micturition  which  causes  retention.  The  early  training  of 
the  nurse  will  have  prepared  her  for  overcoming  mild  cases  of 
retention,  and  the  subject  is  discussed  more  fully  in  Chapter 
III,  page  31 ;  but  she  should  seek  guidance  in  all  cases  of 
failure  to  void  urine  within  a  few  hours  after  recovery  because 
this  is  a  verj-  important  avenue  of  elimination  of  the  anesthetic 
and  any  obstruction  of  it  must  be  promptly  removed. 
■  The  nurse  will  be  guided  by  the  surgeon's  orders  as  to  the 
administration  of  nourishment,  because  this  will  depend  largely 
upon  the  surgical  condition  of  the  patient  as  well  as  upon  the 
individual  customs  of  the  surgeon.  Patients  will  be  very  thirsty 
from  the  earliest  moment  of  recovery  and  will  desire  large 
quantities  of  Avater.  Some  surgeons  will  advise  satisfying  this 
longing  generously,  except,  of  course,  in  stomach  or  other  cases 
where  it  will  be  harmful  to  the  wound  itself ;  and  other  sur- 
geons will  prescribe  extreme  moderation,  even  to  the  extent 
of  allowing  only  small  pieces  of  cracked  ice.  Every  nurse 
knows  that  more  than  the  most  meager  quantity  of  water  ag- 
gravates nausea  and  vomiting  in  the  vast  majority  of  cases,  but 
it  is  also  a  fact  that  plenty  of  water  and  the  usual  prompt  vomit- 
ing of  it  will  often  have  a  sedative  effect  upon  a  turbulent 
stomach  by  cleansing  it  thoroughly  of  the  disturbing  contents. 
This  treatment,  however,  is  so  heroic  that  the  average  nurse 
shrinks  from  it  and  she  should  not  administer  it  except  under 
definite  order  because  there  are  many  cases  in  which  vigorous 


ANESTHESIA  180 

vomiting  would  be  very  dangerous  from  the  surgical  standpoint, 
to  say  nothing  of  the  pain  suffered  by  the  patient.  Further 
discussion  of  this  subject  vv^ill  be  found  in  Chapter  III,  page 
20,  under  post-operative  complications. 

In  cases  where  water  is  forbidden  the  distressing  parched 
condition  of  the  mouth  may  be  relieved  by  sponging  with  a 
lubricating  mouth  wash — one  containing  glycerin,  for  example. 
Rectal  administration  of  salt  solution  may  sometimes  be  em- 
ployed to  relieve  the  extreme  thirst  of  those  patients  who  must 
be  denied  water  by  mouth,  but  this  treatment  is  not  given 
without  definite  order. 

Many  patients  will  be  greatly  distressed  by  the  lingering 
disagreeable  taste  of  the  anesthetic.  The  nurse  may  relieve 
this  with  a  mouth  wash  containing  a  generous  amount  of  lemon 
juice,  tincture  of  myrrh,  etc.,  according  to  the  preference  of  the 
patient. 

The  point  at  which  food  will  be  given  is  also  a  matter  for 
the  surgeon  to  decide,  but  as  this  pertains  more  particularly 
to  the  subject  of  surgical  diet  it  is  discussed  under  that  head- 
ing in  Chapter  XII,  and  in  connection  with  specific  operative 
conditions  in  Chapters  IV-XI. 

Chloroform. — Recovery  from  chloroform  requires  the  same 
watchful  nursing  as  does  that  from  ether,  but  it  is  likely  to 
be  less  eventful.  As  a  rule  the  patient  will  remain  quiet  and 
pass  from  his  anesthesia  into  sound  sleep. 

Nervous  and  excitable  patients  may  have  a  period  of  excite- 
ment which  will  necessitate  the  same  precautions  as  to  restraint 
mentioned  for  ether  subjects,  but  such  cases  will  be  compara- 
tively rare. 

Chloroform  does  not  often  produce  the  profuse  secretion  of 
mucus  nor  the  swollen  tongue  so  usual  in  ether  subjects,  and 
therefore  these  patients  will  not  be  so  prone  to  the  respiratory 
obstructions  which  frequently  complicate  recovery  from  ether. 
In  fact,  it  is  rare  that  the  respirations  will  manifest  any  note- 
worthy feature  beyond  the  characteristic  softness  and  quiet- 
ness. 

Nausea  and  vomiting  will  also  be  less  frequent,  though  when 
vomiting  does  occur  it  is  more  likely  to  be  severe  and  persistent 


190  TEXTBOOK  OF  SURGICAL  NURSING 

thau  after  ether.  The  precautions  mentioned  for  eases  of 
vomitin}?  after  ether  appl.y  equally  to  chloroform  subjects, 
with  the  addition  of  the  one  discussed  in  the  following  para- 
graph. 

Chloroform  subjects  very  frequently  exhibit  considerable 
pallor  and  this  Avill  usually  be  accompanied  by  marked  depres- 
sion of  the  pulse.  These  two  symptoms  are  especially  likely  to 
occur  just  before  or  during  vomiting,  and  as  their  severity  will 
usually  depend  upon  the  severity  of  the  vomiting  and  the  excite- 
ment accompanying  it  the  nurse  can  often  prevent  considerable 
exhaustion  and  even  collapse  by  judicious  management  of  such 
cases. 

The  pulse  is  likely  to  be  comparatively  feeble  throughout  re- 
covery from  chloroform,  and,  as  pointed  out  in  the  preceding 
paragraph,  is  subject  to  periods  of  great  depression.  This  makes 
it  advisable  to  exercise  special  care  to  keep  these  patients  quiet. 
though,  as  we  have  said,  quiet  recovery  is  provided  by  nature  in 
the  great  majority  of  chloroform  subjects. 

Hiccough  will  occur  occasionally,  but  as  in  the  case  of  ether 
it  will  not  often  be  of  great  consequence. 

Bronchial  and  pulmonary  complications  are  not  frequent 
after  chloroform  because  the  anesthetic  is  not  so  irritating  to 
these  parts  and  does  not  cause  the  severe  congestion  of  them 
that  ether  so  often  does.  However,  they  are  not  entirely  un- 
known and  the  nurse  should  not  forget  their  possibility. 

Though  kidney  complications,  beyond  albuminuria,  are  not 
attributed  to  chloroform,  the  voiding  of  urine  is  an  important 
matter  of  nursing  attention,  as  in  the  case  of  ether. 

The  discussion  of  nourishment  in  the  case  of  ether  wdll  apply 
in  general  to  chloroform. 

Ethyl  Chloride. — Complete  recovery  of  consciousness  after 
ethyl  chloride  usually  takes  place  within  a  very  few  minutes. 
Occasionally  there  will  be  a  case  of  collapse,  but  this  will  usually 
occur  before  the  responsibility  for  the  patient  has  been  trans- 
ferred from  the  anesthetist  to  the  nurse.  However,  when  col- 
lapse does  occur  it  is  so  sudden  and  so  profound  that  the  nurse 
should  keep  its  possibility  in  mind. 


ANESTHESIA  191 

Headache,  nausea,  and  vomiting  occur  frequently,  and  they 
may  be  severe. 

The  pulse,  respiratioiis,  and  general  condition  will,  of  course, 
be  carefully  watched  for  some  time,  as  in  all  cases  of  anesthesia. 

Subsequent  treatment  as  to  7iourishment,  etc.,  will  correspond 
in  general  to  that  for  nitrous  oxide  cases. 


For  lack  of  a  more  opportune  moment  we  must  mention  now 
the  matter  of  the  removal  of  the  extra  blankets  with  which  the 
anesthetic  subject  has  been  safeguarded.  There  can  be  no  rigid 
rule  laid  down  as  to  when  this  should  be  done,  as  there  are  too 
many  varying  factors  to  be  considered.  Some  of  the  deter- 
mining factors,  excepting  the  self-evident  one  of  recovery  from 
the  anesthetic,  are  these :  The  particular  anesthetic  given ; 
length  of  the  anesthesia ;  condition  of  the  patient ;  season  of  the 
year;  temperature  of  the  room;  and,  of  course,  always  the 
subjective  comfort  of  the  patient.  For  the  same  reason  that 
the  blankets  were  put  on,  care  must  be  exercised  as  to  their  re- 
moval; that  is,  there  must  be  no  chance  of  exposure  taken.  In 
this  respect  error  may  be  made  in  both  directions,  for  it  is  as 
much  a  mistake  to  leave  these  blankets  on  so  long  after  recov- 
ery that  the  patient  becomes  unduly  warm  as  it  is  to  take  them 
off  before  nature's  "heating  plant"  is  in  working  order.  In 
hospitals  there  will  usually  be  an  established  routine,  and  else- 
where the  nurse  will  need  to  draw  upon  her  professional  good 
judgment.  Entire  recovery  from  the  anesthetic  is  the  first 
requisite.  This  will  mean  that  nitrous  oxide  and  ethyl  chloride 
patients,  if  they  have  blankets  at  all,  Avill  not  need  them  as  long 
as  ether  and  chloroform  subjects.  A  vigorous,  generally  healthy 
subject  will  recover  all  his  functions  much  sooner  after  any 
anesthetic  than  a  weak,  devitalized  one.  After  recovery  the 
patient  in  poor  condition  may  need  protection  further,  while  the 
stronger  one  may  not.  In  winter  longer  protection  will  be 
needed  than  in  summer.  In  a  warm  room  more  freedom  can 
be  taken  than  in  a  cold  one.  In  the  daytime  patients  have 
better  resistance,  on  the  whole,  than  at  night.  And  last  but 
not  least,  the  patient's  feelings,  which  always  have  an  influence 
upon  his  condition,  will  enter  into  the  case  to  some  degree. 


192  TEXTBOOK  OF  SURGICAL  NITRSING 

Naturally,  this  transition  is  accomplished  gradually,  that  is, 
these  special  blankets  are  not  all  -svithdraAvn  at  one  time.  This 
much  having  been  said,  common  sense  Avill  do  the  rest. 

All  nursing  care  following  an  anesthetic  must  be  a  fusion  of 
that  which  pertains  particularly  to  the  anesthesia  and  of  that 
demanded  by  the  surgical  condition  of  the  patient.  We  have 
necessarily  disregarded  surgical  conditions  here,  but  their  im- 
portant nursing  care  is  pointed  out  under  the  discussions  of 
the  various  operative  procedures  in  Chapters  IV  to  XI ;  under 
shock  and  hemorrhage,  in  Chapter  II ;  under  post-operative  com- 
plications, in  Chapter  III ;  and  under  surgical  dietetics  in  Chap- 
ter XII.  By  combining  the  discussions  of  the  subject  from 
these  several  standpoints  the  nurse  can  formulate  for  herself 
the  befitting  twofold  course  of  action  demanded  of  her  for  each 
individual  case. 


CHAPTER  XIV 

ARRANGEMENT,    ORGANIZATION,    AND    EQUIPMENT    OF    THE 
OPERATING   THEATER 

Operating  room  nursing  is  one  of  the  advanced  subjects  of 
the  profession  and  should  not  be  undertaken  until  the  student 
has  had  a  long  period  of  general  training  in  bedside  nursing 
and  her  courses  of  instruction  in  general  theory,  bacteriology, 
solutions,  materia  medica,  etc.;  for,  while  she  will  learn  much 
in  the  operating  room  that  is  new  to  her,  the  work  there  is  very 
largely  a  matter  of  piecing  together  and  developing  the  frag- 
ments of  knowledge  and  practice  of  her  preliminary  courses. 

The  task  of  teaching  operating  room  nursing,  and  particularly 
the  organization  and  management  of  it,  to  any  great  degree  of 
detail  is  a  very  difficult  one  because  so  many  variations  must 
be  allowed  for  individual  preferences  of  surgeons,  the  equip- 
ment provided  by  the  given  hospital,  and  the  number  and  quali- 
fications of  the  members  of  the  staff.  There  is  no  one  known 
plan  which  can  be  called  superior  to  all  others,  nor  need  there 
be,  for  if  the  student  masters  the  fundamental  principles  of 
asepsis  and  antisepsis  and  has  at  least  the  average  amount  of 
common  sense  and  a  logical,  systematic  turn  of  mind  she  can 
adapt  these  principles  so  as  to  work  out  a  good  system  under 
any  given  set  of  conditions.  We  shall  not  attempt,  therefore, 
to  tell  you  how  to  organize  and  conduct  a  model  operating 
room,  but  rather,  we  shall  try  so  to  instruct  you  in  foundation 
principles  that  you  may  equip  yourself  to  organize  and  manage 
one  that  will  be  a  model  for  your  particular  limitations  or  ad- 
vantages. 

As  we  shall  try  to  present  this  subject  so  as  to  make  it  useful 
for  all  classes  of  readers,  each  one  will  necessarily  find  much 
that  will  not  be  of  value  nor  interest  in  her  particular  case ;  but 
the  nature  of  the  subject  makes  this  inevitable,  so  we  must  beg 
your  indulgence  for  those  parts  which  may  seem  too  elementary 

193 


194  TEXTHOOK  OF  SURGICAL  NURSING 

or  self-evident  to  you,  or  whieh  seem  very  foreign  to  your  case, 
and  ask  you  to  believe  ^vith  us  that  they  -will  meet  the  needs 
of  someone  else. 

Mueli  that  must  be  said  here  to  make  the  discussion  com- 
plete -will  be  of  more  value  if  studied  in  combination  with  the 
practical  experience  in  the  operating  room  itself;  but  the  prac- 
tice of  plunging  a  puiiil  directly  into  the  actual  work  from 
which  she  is  expected  to  gather  her  knowledge  as  occasion 
chances  to  present  itself  is  to  leave  her  education  too  much  to 
the  mercj'  of  her  own  enthusiasm  and  the  uncontrollable  irregu- 
larities of  the  work.  A  few  preliminary  classroom  lessons  be- 
fore she  is  rushed  into  the  confusion  and  excitement  of  the 
operating  room  Mill  conserve  much  of  the  pupil's  nervous 
energy,  will  save  much  valuable  time  for  both  herself  and  the 
other  members  of  the  staff,  and  she  will  have  a  sounder  edu- 
cation for  having  acquired  it  in  an  orderly,  logical  way. 

We  strongly  advocate  the  doctrine  that  every  nurse  should 
be  given  a  thorough  course  in  operating  room  technic,  not  only 
because  of  the  countless  number  of  additional  facts  she  learns 
thereby  which  are  essential  to  the  highest  efficiency  in  what- 
ever specialty  she  may  adopt  after  she  has  graduated,  but  also 
because  of  the  general  educational  value  of  the  discipline  it 
gives  her  in  alertness,  accurateness,  and  promptness  of  re- 
sponse. However,  there  are  relatively  few  nurses  who  should 
aspire  to  become  operating  room  "specialists,"  because  the 
work  is  a  highly  specialized  type  of  nursing,  and  certain  natural 
as  well  as  cultivated  qualifications  are  necessary  for  more  than 
mediocre  efficiency  in  it.  We  do  not  know  any  more  about  the 
universally  model  operating  room  nurse  than  we  knew  a  few 
moments  ago  about  the  universally  model  operating  room  itself, 
but  a  few  pages  hence  we  shall  attempt  to  set  up  a  few  stand- 
ards which  will  apply  universally. 


A  thoroughly  logical  sequence  in  the  presentation  of  the  al- 
most innumerable  phases  of  this  subject  is  very  difficult  to  ar- 
range, but  as  a  nurse  knows  in  a  general  way,  before  taking 
up  this  course,  what  an  operating  room  is  for,  she  will  perhaps 


EQUIPMENT  OF  THE  OPERATING  THEATER    105 

do  best  by  beginning  here  with  a  picture  of  its  general  arrange- 
ment and  equipment. 

THE  ROOMS  AND  THEIR  FURNISHINGS 

Ideally  the  operating  theater  comprises  these  rooms : 

1.  Operating  room  proper 

2.  Anesthetizing  room 

3.  Dressing  room  for  surgeons 

4.  Dressing  room  for  nurses 

5.  Recovery  room 

6.  Work  room  for  nurses 

7.  Sterile  supply  room 

8.  Sterilizing  room 

9.  Storage  room 

Of  course,  this  exact  number  of  rooms  may  never  be  available, 
but  they  do  represent  departments,  and  whatever  space  is  pro- 
vided should  be  subdivided  and  arranged  with  these  separate 
features  in  mind.  By  the  time  you  have  finished  this  chapter 
we  shall  hope  to  have  assisted  you  to  enough  ideas  to  enable 
you  to  make  the  best  combination  of  these  departments  which 
your  space  permits. 

"When  practicable  the  operating  theater  is  on  one  of  the  higher 
floors  of  the  building  because  in  this  location  it  is  most  likely 
to  be  isolated  from  miscellaneous  traffic  and  undue  noise  and 
dust,  all  of  which  are  menaces  and  nuisances  to  an  operating 
room. 

1.  The  Operating  Room  Proper. — a.  Construction. — This  is, 
of  course,  a  light  room  and  it  has  a  northern  exposure  if  pos- 
sible because  of  the  better  diffusion  of  light  it  will  furnish  than 
one  into  which  strong  rays  of  sunlight  stream  in  some  parts,  caus- 
ing deep  shadows  in  others ;  and  a  skylight  will  be  an  addi- 
tional advantage.  The  size  of  the  room  is  best  no  larger  than 
is  necessary  for  holding  the  equipment  and  allowing  the  mini- 
mum space  for  comfort  in  moving  about.  Too  large  a  room 
is  wasteful  of  time  and  steps,  and  too  small  an  one,  of  course, 
will  be  too  congested  for  the  easy  maintenance  of  asepsis,  be- 
cause there  are  always  the  sterile  and  the  unsterile  equipment 


191)  TEXTBOOK  OF  SURGICAL  NURSING 

ill  more  or  less  eloso  association.  Unless  one  has  the  })leasure 
of  plaimiiig  the  constructioii  of  her  o\\ii  operating  room,  how- 
ever, she  will  not  be  able  to  control  this  feature  of  the  matter 
beyond  exereising  good  judgment  as  to  arrangement  of  con- 
tents and  organization  of  routine  i)ractices. 

It  ought  not  to  be  necessary  to  remind  you  that  the  walls, 
floors,  and  all  other  structural  parts  of  the  room  should  be 
finished  in  the  most  hygienic  way  possible;  that  is,  they  should 
be  of  some  material  that  can  be  easily  washed  and  that  will  not 
catch  or  hold  dust  readily,  for  example,  tiling,  enamel  paint, 
etc.  Those  of  you  who  have  had  the  advantages  of  training 
in  a  hospital  built  on  modern  architectural  principles  will  have 
observed  the  curve,  for  instance,  in  which  the  wall  and  the 
floor  meet  instead  of  the  old-fashioned  right-angle  which  is 
such  a  safe  harbor  for  dust  and  such  a  good  incubator  for 
germs;  you  will  probably  have  noticed  also  that  the  corners 
of  the  walls  are  fashioned  similarly;  also,  the  window  ledges 
were  probablj^  slanting  or  curved,  and  all  window  casings,  door 
casings,  and  other  finishings  were  as  free  as  possible  from  nooks 
and  corners.  This  has  all  been  provided  for  you  and  you  have 
taken  it  for  granted,  but  you  should  appreciate  the  principles 
involved  so  that  if  it  falls  to  your  lot  at  some  time  to  control  the 
adaptation  or  constructioii  of  some  room  for  operating  pur- 
poses you  may  be  able  to  be  of  the  best  service. 

On  this  same  principle,  a  good  technician  does  not  provide 
wall  hooks  in  her  operating  room  upon  which  careless  persons 
may  hang  various  articles  which  lumber  up  the  room  and  en- 
courage contamination.  The  storage  and  supply  rooms  are  the 
proper  places  for  all  articles  which  are  not  needed  for  the  opera- 
tion, and  between  operations  the  storage  and  supply  rooms  are 
the  places  for  everything  except  the  more  non-transportable  fur- 
niture. Under  some  conditions  of  room  arrangement  where 
space  is  limited  the  operating  room  may  have  to  bear  a  part  of 
the  burden  of  storage,  but  in  any  ease  one  must  always  follow 
the  principle  of  keeping  all  supplies  protected  as  far  as  pos- 
sible. This  practice  is  not  only  refined  technic  but  it  is  also 
simple  common  sense  in  that  it  saves  the  time  and  labor  of 
unnecessary  renovation. 


EQUIPMENT  OF  THE  OPERATING  THEATER    197 

Good  ventilation  must  be  provided,  and  some  way  should  be 
found  to  do  this  without  permitting  a  draught  directly  through 
the  room. 

Heat  should  he  generous,  as  the  temperature  of  an  operating 
room  should  be  maintained  at  75°  or  76°  F. 


Fig.  22. — Two  of  the  More  Elaborate  Types  of  Operating  Table. 


h.  Furniture. — The  ideal  material  for  all  operating  room  fur- 
niture is  white-enameled  metal,  as  it  is  durable  and  sanitary. 

The  first  essential  is  the  operating  table.  There  are  innumer- 
able models  on  the  market  and  the  one  chosen  will  depend  upon 
financial  resources,  preference  of  the  surgeon,  etc.    (Fig.  22). 


198  TEXTBOOK  OF  SURGICAL  NURSING 

Many  of  the  more  expensive  tables  are  very  complex  in  their 
mechanism,  and  as  the  average  nurse  is  not  mechanically  in- 
clined she  finds  it  difficult  to  learn  how  to  manipulate  them ; 
but  as  it  usually  falls  to  her  lot  to  see  that  the  patient  is  placed 
in  the  proper  position  for  the  operation,  she  should  consider  it 
her  business  to  master  the  mysteries  of  her  table,  as  all  the  at- 
tachments and  adjustments  serve  some  helpful  purpose  if  the 
responsible  person  knows  how  to  put  them  to  their  intended 
use  expertly.  Tliis  may  seem  a  minor  detail  but  operating 
room  work  is  made  up  of  detail,  and,  like  a  delicately  adjusted 
machine,  if  one  part  functions  poorly  it  is  very  likely  to  cause 
embarrassment  to  the  whole  machine.  For  instance,  in  the  case 
of  operations  upon  the  kidney  we  have  seen  it  necessary  for  the 
surgeon,  after  struggling  many  precious  minutes  against  the 
handicap  of  an  improper  position  of  the  patient,  to  stop  operat- 
ing, dress  the  wound  temporarily,  unsterilize  his  gloves  and 
gown,  and  adjust  the  patient's  position  himself.  This  is  an 
extreme  illustration  because  of  the  fact  that,  for  anatomical 
reasons,  the  kidney  is  difficult  of  access  in  the  best  of  positions, 
but  corresponding  annoyances  in  many  other  cases  may  arise 
from  lack  of  intimate  acquaintance  with  this  very  essential  arti- 
cle of  equipment. 

One  or  two  instrument  tables  are  the  next  essentials.  If 
there  is  but  one  operation  to  be  done  one  table  is  enough,  but 
where  there  is  to  be  a  session  of  several  cases  it  will  be  necessary 
to  have  a  second  table  for  the  reserve  supplies.  Many  varieties 
are  in  use  (Fig.  23)  and  there  is  no  importance  in  the  design 
of  any  one  except  w^hen  one  is  desired  which  can  be  placed 
across  the  operating  table  near  enough  to  the  w^ound  so  that 
the  surgeon  can  pick  up  the  instruments  from  it  himself.  For 
this  purpose  a  type  similar  to  the  one  illustrated  in  Fig.  24 
wall  be  needed.  This  is  a  very  serviceable  table,  as  it  is  ad- 
justable in  height,  is  on  rollers,  and  can  thus  be  easily  adapted 
and  moved  as  convenience  requires. 

A  tahle  for  dressings  and  other  miscellaneous  supplies  will  be 
needed  in  nearly  every  case.  This  should  be  no  larger  than 
necessary. 

One  or  more  stretchers  are  necessary.     In  a  large  hospital 


EQUIPMENT  OF  TUB  OPERATING  THEATER    199 

where  space  permits  and  elevators  are  used,  the  wheel  stretcher 
(Fig.  25)  will  be  the  one  to  provide,  but  in  many  smaller  in- 


FiG.   23. — Two  Varieties  of  Instrument   Table, 

stitutions  the  carrying  variety   (Fig.  26)   can  be  made  to  an- 
swer all  purposes;  but  w^here  there  is  much  carrying  up  and 


Fig.  24. — Adjustable  Ixstrujikxt  Table  Which  May  be  Extended 
Across  the  Operating  Table  in  Any  Location  Desired.  The  cover  shown 
is  the  one  described  on  page  216,  paragraph  No.  13. 

'down  stairs  to  be  done  the  special  design  shown  in  Fig.  27  is 
very  serviceable. 


200 


TEXTBOOK  OF  SURGICAL  NURSING 


A  tub  or  large  basin  holding  ()  or  8  gallons  will  be  needed  in 
large  operating  rooms  for  a  1-1000  solution  of  bichloride  •which 
will  serve  many  useful  purposes  from  time  to  time. 


Fig.  25. — Wheel  Stretcher. 


Other  minor  articles  for  this  room  are,  a  seat  for  the  anes- 
thetist or  surgeon  (Fig.  28)  ;  possibly  a  small  table  for  unsterile 


Fig.   26. — Carrying  Stretcher.     This  is,   in  general   outline,   the   U.   S. 

Army  type. 


Fig.  27. — Stretcher  Suitable  for  Carrying  Patients  Up  and  Down 
Stairways.  It  is  merely  a  bent  iron  tube  covered  with  canvas  slip  covers. 
Some  models  have  a  single  piece  of  canvas  shaped  like  the  frame  and 
laced  to  it  with  a  strong  cord  passed  through  eyelets  in  the  border  of  the 
canvas. 


supplies  such  as  adhesive  plaster,  bandages,  etc. ;  and  a  set  o£ 
loiv  beiiches  (Fig.  29)  of  differing  heights  for  the  surgeon  to 
stand  upon  for  some  operations.     These  should  range  in  height 


EQUIPMENT  OF  THE  OPERATING  TITEATEl?     201 

from  4  inches  to  1  foot,  and  they  should  be  about  1  foot  wide  and 
2  feet  long.  Various  kinds  can  be  purchased  from  hospital 
supply  companies,  but  they  do  not  furnish  the  useful  grada- 
tions in  height,  and  as  they  are  usually 
made  of  metal  they  are  not  so  con- 
venient to  handle  as  are  the  simple 
wooden  ones  suggested  in  the  illustra- 
tion. 

A  good  artificial  light  is  of  course 
necessary,  but  the  only  general  sugges- 
tions that  can  be  offered  about  this  are 
that  it  should  be  so  placed  that  the 
operating  table  need  not  be  moved 
when  a  shift  is  made  from  the  daylight 
to  the  artificial  one ;  and  that  it  should 
be  simple  in  its  fittings  for  sanitary 
reasons.  Unless  one  has  an  elaborately 
adjustable  one  it  should  be  supple- 
mented by  a  simple  "drop' 
light  (Fig.  30)  which  will  be  needed 
occasionally  in  the  case  of  a  deep  or  inaccessible  wound.  The 
type  shown  in  the  illustration  can  be  draped  with  a  sterile 
towel  when  necessary. 

This  is  enough  furniture  to  get  along  with,  and  the  guiding 


or  hand  i'lG.    28.— Seat    for    the 
Anesthetist  ob  Surgeon. 


Fig.  29. — Bench  for  the  Surgeon  to  Stand  Upon  When  the  Operat- 
ing Table  Cannot  be  Adjusted  Suitably  in  Height.  These  may  be  very 
simply  made  of  wood,  and  several  heights  will  be  useful. 


principle  in  amount  of  furniture  should  be  not  to  encumber 
the  room  with  more  than  is  reasonably  necessary. 

There  is  one  other  item  to  be  mentioned  in  this  connection 
because,  while  not  a  necessity,  it  is  a  great  convenience  and  a 


202 


TEXTBOOK  OF  SURGICAL  NURSING 


general  favorite.  It  is  the  ''drum"  (Fig.  31),  or  metal  con- 
tainer in  which  the  dressings  and  other  fabrics  are  sterilized  and 
from  Avhich  they  are  used  directly  while  the  operation  is  in 


Fig.  30. — Hand  Light. 

progress.  It  is  made  with  perforations  which  are  opened  to 
admit  the  steam  while  in  the  sterilizer,  and  closed  afterward, 
making  the  drum  very  safe  and  dust-tight. 
Th'e  lids  of  these  drums,  when  in  use,  are 
opened  and  closed  by  means  of  a  foot  lever 
on  a  speciall}^  fitted  stand,  and  they  thus 
provide  a  very  convenient  storage  me- 
dium. For  a  complete  system  several 
drums  will  be  needed ;  for  example,  the 
gloves  cannot  be  kept  with  the  wound 
dressings  because  they  are  covered  with 
talcum  powder  and  this  sifts  from  them 
when  they  are  handled;  also,  for  reasons 
which  you  will  learn  later,  it  is  not  good 
technic  to  store  the  sterile  gowns  with  the 
wound  dressings;  and  it  may  not  be  con- 
venient to  have  the  draping  sheets  and 
towels  in  the  same  part  of  the  room,  or 
even  in  the  same  room,  with  any  of  the 
other  supplies.  Thus,  you  will  need  at 
least  four  drums  if  you  have  any,  and 
when  this  system  is  used  there  is  usually  included  a  fifth  drum 
for  hot  wet  towels  and.  pads  (Fig.  32).  Here  we  must  digress 
somewhat  to  say  that  this  hot  towel  drum  is  similar  to  the  others 
except  that  it  is  perforated  in  the  bottom  and  is  fitted  over  a 


Pig.  31.  —  Dress- 
ing Drum  with  Ped- 
al Opening  Stand- 
ard. 


EQUIPMENT  OF  THE  OPERATING  THEATER    203 

small  water  tank  which  is  heated  electrically  or  otherwise,  thus 
allowing  the  towels  to  become  wet  and  heated  by  the  steam.  Be- 
sides the  set  of  drums  in  use,  as  outlined,  there  will  be  needed 
reserve  ones,  so  this  involves  a  considerable  equipment  which  will 
be  too  expensive  in  some  instances ;  and  besides  there  will  some- 
times be  the  consideration  of  storage  space  because  these  stands 
and  drums  require  more  space  for  a  given  amount  of  contents 
than  do  the  simple  muslin-covered  parcels  which  you  would 
otherwise  use. 


Fig.  32. — Hot  Towel  Drum 
WITH  Pedal  Opening  Standard  and 
Electrically  Equipped  Steaming 
Device. 


Fig.   33. 


-Instrument  Steril- 
izer. 


c.  Sterilizers. — Where  space  permits  the  instrument  sterilizer 
(Fig.  33)  should  be  within  the  operating  room  and  as  near  the 
instrument  table  as  is  practicable  and  safe,  because  frequent 
reboiling  of  instruments  is  usually  necessary  during  an  opera- 
tion and  it  saves  time  and  handling  if  the  person  responsible 
for  the  instruments  has  direct,  easy  access  to  this  boiler.  When 
this  sterilizer  is  heated  by  gas  or  any  other  open  flame  it  must 
be  stationed  a  safe  distance  from  the  anesthetist  because  ether, 
chloroform,  and  ethyl  chloride  are  highly  inflammable.     Fur- 


204 


TEXTBOOK  OF  SURGICAL  NURSING 


thermore,  extreme  heat,  and  particularly  an  open  flame,  will 
decompose  chloroform  vapor  and  produce  phosgene  and  hydro- 
chloric acid  gases  -which,  in  a  small  or  poorly  ventilated  room, 
may  cause  serious  trouble  by  their  irritant  effect  upon  the  eyes 
and  the  respiratory  tract. 

In  some  cases  one  sterilizer  may  have  to  suffice  for  all  other 
supplies  as  well  as  the  instruments;  but  where  possible  there 
should  be  another  large  utensil  sterilizer  (Fig.  34)  for  large 
basins,  etc.  This  should  be  in  the  operating  room  also  when 
possible. 

Besides  the  reason   of  convenience  for  having  these  boilers 

within  the  room,  there  is  the 
technical  reason  that  t'he  steam 
which  they  give  off  renders  the 

i-r— K-«-^^^^^^t^^^^^mi^  air  moist  and  thereby  keeps 
L  w^I^^^^BbII^^HB  do\vn  dust  which  might  some- 
■m*^^^^^  (-^^HB      times  be  a  real  menace  in  a  dry 

atmosphere. 

Water  Sterilizers  (Fig.  35), 
one  for  hot  sterile  water  and  one 
for  cold,  and  equipped  with  a 
filter,  will  also  be  necessary. 
These  are  perhaps  best  placed 
outside  of  the  operating  room, 
but  their  outlets  should  be  ex- 
tended into  the  room  at  some 
easily  accessible  point. 
d.  Miscellaneous  Equipment. — There  are  a  great  many  other 
devices  which  are  in  more  or  less  general  use  and  which,  if 
properly  fitted  into  a  corresponding  general  system,  simplify 
the  work.  In  fact,  those  who  have  become  accustomed  to  the 
more  elaborately  outfitted  operating  rooms  and  who  have  never 
been  compelled  to  work  more  primitively  will  consider  indis- 
pensable many  of  these  items ;  but  as  they  are  more  or  less 
luxuries  we  shall  not  take  space  here  to  enumerate  them. 

2.  The  Anesthetizing  Room. — a.  Construction. — The  finish- 
ing of  the  walls,  floors,  etc.,  should  be  similar  to  that  described 
for  the  operating  room,  because  where  there  is  a  separate  room 


Fig.  34. — Utexsil  Sterilizer. 


EQUIPMENT  OF  TTIE  OPERATING  THEATER    205 

for  this  purpose  all  of  the  final  preparation  of  the  patient  is 
done  in  it  and  it  should  therefore  be  sanitarily  fitted.  It  should 
be  a  reasonably  spacious  room  because  a  great  deal  of  both 
sterile  and  unsterile  work  will  be  done  in  it,  and,  as  pointed 


Fig.  35. — Hot  and  Cold  Water  Sterilizers.  The  small  cylindrical  at- 
tachment between  them  contains  a  clay  filter  through  which  the  water  is 
forced  before  it  enters  the  tanks  to  be  sterilized.  This  filter  is  removable 
and  must  be  cleansed  often  by  scrubbing  under  running  water  with  a  very 
stiff  brush.  The  cold  water  tank  has  a  coil  of  tubes  running  through  its 
interior  through  which  cold  water  may  be  run  for  cooling  the  sterile  water 
after  it  has  been  boiled.  These  sterilizers  are  built  to  withstand  high 
steam  pressure  and  are  usually  adjusted  so  that  the  water  may  be  ster- 
ilized under  15  pounds  pressure  which,  as  will  be  explained  later  (page  239), 
raises  its  temperature  about  38°  F.  higher  than  that  of  boiling  water. 


out  for  the  operating  room,  there  must  be  ample  room  for  keep- 
ing the  sterile  equipment  well  out  of  the  way  of  the  unsterile. 

Ventilation  and  heating  should  correspond  with  that  of  the 
operating  room. 

&.  Furniture. — First  of  all,  there  must  be  a  table  or  a  wheel 


206  TEXTBOOK  OF  SURGICAL  NURSING 

stretcher  for  the  patient.  In  jrenerously  o(iiii[)i)ed  operating 
rooms  where  several  operations  are  done  in  iiinuediate  succes- 
sion there  will  doubtless  be  an  extra  operating-  table  for  this  pur- 
pose and  the  patient  will  be  anesthetized  upon  the  table  upon 
which  the  operation  is  to  be  performed.  Otherwise,  a  wheel 
stretcher  or  some  other  type  of  table  will  be  needed. 

There  will  also  be  needed  a  small  table  for  the  anesthetist's 
supplies.  This  may  be  one  that  is  fitted  with  wheels  so  that 
it  may  be  taken  into  the  operating  room  during  the  operation, 
but  the  articles  needed  by  the  average  anesthetist  after  the 
anesthesia  is  established  are  so  few  that  it  is  perhaps  not  ad- 
visable to  have  more  than  a  simple  stationary  stand  in  the  an- 
esthetizing room. 

A  tahlc  for  miscellaneous  articles  will  be  necessary  and  this 
one  should  be  spacious  because  when  the  preparation  and  sterile 
draping  of  the  patient  are  done  in  this  room  expediency  will 
require  that  many  odds  and  ends,  such  as  sandbags,  pillows, 
rubber  sheets,  operating  table  attachments,  etc.,  be  within  easy 
reach. 

When  there  is  enough  space  to  make  it  technically  safe  the 
sterile  draping  supplies  may  be  kept  in  this  room  during  opera- 
tions and  for  this  purpose  there  will  be  needed  another  tahle, 
except  when  the  "drums"  are  used,  in  which  case  one  packed 
exclusively  with  draping  sheets  and  towels  will  take  the  place 
of  this  table.  The  drum  is  so  securely  closed  that  there  can 
never  be  any  objection  to  having  it  in  the  anesthetizing  room. 

A  chair  or  two  may  be  useful  in  this  room. 

When  limited  space  makes  a  separate  anesthetizing  room  im- 
possible, the  anesthetic  will  be  administered  in  the  operating 
room  itself,  and  this  will  require  great  caution  as  to  the  sterile 
drapings  and  supplies,  for  there  is  always  more  or  less  commo- 
tion attendant  upon  the  induction  of  the  anesthesia  and  the 
preparation  of  the  patient  in  the  form  of  struggling  of  the 
patient  and  the  necessary  handling  of  blankets,  etc. 

3.  Dressing  Room  for  Surgeons. — a.  Construction. — The 
walls  and  floors  of  this  room  should  be  similar  to  those  of  the 
operating  room. 

b.  Furniture. — Wash  basins  with  hot  and  cold  running  water 


EQUIPMENT  OF  THE  OPERATING  THEATER    207 

are  the  important  essentials  of  this  room,  and  if  possible  pedal 
faucets  (Fig.  36)  should  be  installed  with  them.  The  number 
of  basins  will  depend  upon  circumstances  and  the  number  of 
surgeons  operating  at  one  time. 

One  or  more  "arm  hasins"  should  be  provided  for  the  anti- 
septic solution  in  which  the  hands  and  arms  are  sterilized  after 
scrubbing.  Standard  ones  (Fig.  37),  holding  enough  solution 
so  that  the  whole  arm  up  to  the  elbow  may  be  immersed  are 
best,  but  large  ones  of  other  design  will  serve. 


Fig.  36. — Wash  Basins  Equipped  with  a  Pedal  Device  fob  Turning 
THE  Water  On  and  Off,  and  with  a  ' '  Goose-Neck  ' '  Faucet,  Which  Per- 
mit Scrubbing  of  the  Hands  and  Arms  Without  Contaminating  Them 
During  the  Process, 


Where  possible  individual  lockers  should  be  provided  in  this 
room  for  the  surgeons. 

Some  provision  must  be  made  for  the  surgeons'  sterile  suits 
or  gowns.  The  drum  answers  this  purpose  admirably,  but  in 
lieu  of  this  a  table  will  be  needed  for  these  sterile  supplies  which 
will  be  packed  in  individual  parcels  or  stored  immediately  in 
advance  on  the  sterilly  draped  table. 

A  few  chairs  will  be  appreciated  in  the  dressing  room. 

4.  Dressing  Room  for  Nurses. — This  room  should  be  essen- 
tially the  same  in  equipment  as  the  one  for  the  surgeons,  but 


208 


TEXTBOOK  OF  SURGICAL  NURSING 


it  may  not  need  to  be  as  large,  though  this  will  depend  upon 
the  relative  number  of  nurses  using  it. 

5.  Recovery  Room. — Where  space  and  nurses  are  plentiful 
one  room  may  be  equipped  with  one  or  more  beds  and  with 
paraphernalia  for  the  resuscitation  of  the  occasional  patient 
who  may  need  immediate  treatment.  In  other  cases  this  room 
will  be  CQnvenient  for  use  in  transferring  the  patient  from 
the  operating  table  to  the  stretcher,  and  for  the  application  of 
bandages,  plaster  casts,  splints,  etc. 


Fig.  37. — Two  Types  of  Arm  Basin. 


6.  Work  Room  for  Nurses. — a.  Construction. — This  is  a 
department  of  the  operating  theater  which  is  often  neglected  in 
hospital  architecture,  for  the  fact  is  probably  overlooked  that 
it  is  in  this  room  that  the  nurse  spends  the  major  part  of  her 
time  and  does  the  bulk  of  her  work.  For  this  reason  the  w^ork 
room  should,  first  of  all,  be  well  lighted  both  naturally  and 
artificially,  and  of  course  well  ventilated  and  comfortably 
heated.  While  it  is  advisable  that  this  room  should  be  sani- 
tarilj'  finished  on  the  general  principles  of  the  operating  room, 
it  is  not  so  important. 

h.  Furniture. — Ample  tvorh  tables,  chairs,  dust-proof  storage 


EQUIPMENT  OF  THE  OPERATING  THEATER    209 

shelves  and  closets,  a  gas  or  other  stove,  and  spacious  washing 
sinks  cover  the  essential  furnishings  for  this  department. 

7.  Sterile  Supply  Room. — Where  practicable  this  room 
should  be  reserved  entirely  for  the  sterile  supplies,  and  it 
should,  of  course,  be  kept  as  free  as  j^ossihle  from  dust  and 
moisture.  We  would  caution  nurses  with  limited  space  at  their 
disposal  to  employ  only  as  a  last  resort  any  part  of  the  work 
room  for  the  storage  of  sterile  supplies,  as  it  will  probably  be 
the  least  clean  room  of  all. 

8.  Sterilizing  Room. — a.  Construction. — The  walls  and 
floors  of  this  room  must  be  finished  so  as  to  be  waterproof,  as  the 
steam  from  the  sterilizers  will  ruin  anything  else,  and  water  will 
unavoidably  be  spilled  upon  the  floor  from  time  to  time.  This 
room  must  be  well  ventilated,  and  because  of  the  water  in  the 
sterilizers  and  plumbing  it  must  be  well  heated  to  prevent  freez- 
ing in  winter  time. 

&.  Furniture. — A  work  table  will  be  needed,  and  perhaps 
storage  shelves,  but  this  will  depend  upon  whether  the  packing 
of  the  supplies  for  sterilization  is  done  in  this  room  or  in  the 
nurses'  work  room. 

The  chief  equipment  is  the  steam  dressing  sterilizer  (see  Fig. 
49,  page  238).  The  number,  size,  and  variety  will  be  governed 
by  innumerable  conditions,  but  it  must  be  remembered  that  only 
those  which  provide  for  live  steam  sterilization  under  pressure 
in  a  vacuum  are  to  be  depended  upon  for  absolute  sterilization, 
particularly  of  large  parcels  which  are  difficult  of  penetration 
by  the  steam. 

If  a  room  cannot  be  devoted  entirely  to  this  purpose  the 
sterilizing  department  may  have  to  be  combined  with  either  the 
work  room  or  the  supply  room,  or  even  both,  but  strong  objec- 
tions to  storing  the  sterile  supplies  in  the  sterilizing  room  are 
that  the  steam  keeps  the  room  damp,  and  there  is  always  danger 
of  water  being  spilled  upon  the  sterile  parcels  which  will,  of 
course,  unsterilize  them. 

9.  Storage  Room. — This  will  be  a  convenient  room  to  have 
in  which  to  keep  infrequently  used  and  reserve  unsterile  sup- 
plies, and  miscellaneous  portable  appliances,  but  in  its  absence 
the  nurses'  work  room  may  have  to  serve  instead.     As  ad^dsed 


210  TEXTBOOK  OF  SURGICAL  NURSING 

above,  have  some  corner  devoted  to  this  class  of  supplies  and 
form  the  habit  of  leaving  nothing  portable  in  the  operating 
room  which  has  no  useful  immediate  function  to  perform  there. 

THE  PERSONNEL 

The  scene  is  now  laid  and  we  have  a  roughly  furnished  oper- 
ating theater.  Before  we  go  further  we  shall  put  some  people 
into  it  to  do  the  hundreds  of  things  wliich  remain  to  be  done 
before  we  are  ready  for  our  patient. 

1.  Personal  Qualifications. — In  the  first  place,  one  must  be 
very  strong  physically  to  endure  the  strain  and  severity  of  oper- 
ating room  work.  Hours  of  application  are  likely  to  be  longer, 
and  at  all  times  the  work  is  more  intense  than  in  any  other  type 
of  nursing,  and  a  strong  body  is  the  only  one  that  will  hold  out 
to  the  bitter  end. 

Patience  and  forbearance  are  also  more  in  demand,  and  for 
longer  periods  than  elsewhere.  The  nature  of  the  work  re- 
quires that  no  time  be  lost  and  no  mistakes  made,  and  conse- 
quently everybody  is  more  or  less  under  nervous  tension,  which 
means  that  the  nurse  will  not  always  receive  the  consideration 
from  her  superior  officers  which  she  has  been  accustomed  to 
receiving  in  other  lines  of  her  work.  Orders  are  more  numer- 
ous, and  often  conflicting,  and  if  the  nurse  has  not  the  maxi- 
mum amount  of  the  proverbial  patience  and  self-effacement 
which  are  always  urged  upon  her  profession  she  will  often  fare 
rather  uncomfortably  in  the  operating  room. 

Alertness  of  mind,  self-control,  and  promptness  of  conversion 
of  thought  into  action  are  other  indispensable  qualifications  for 
real  efficiency.  A  patient  is  under  an  anesthetic  and  under- 
going interference  with  his  life  mechanism,  which  means  that 
emergencies  are  always  arising,  and  the  nurse  who  "loses  her 
head"  is  not  popular,  to  say  the  least,  on  an  operating  room 
staff. 

Conscientiousness,  though  essential  and  presupposed  through- 
out the  professional  activities,  is  obligatory  here.  "When  an  op- 
erating room  nurse  reflects  that  a  single  chance  taken  under 
pressure  of  orders  or  time  may  cost  the  health  or  even  the  life 


EQUIPMENT  OF  THE  OPERATING  THEATER    211 

of  another  person  she  will  never  yield  to  any  circumstance  on 
this  point. 

While  all  the  foregoing  qualifications  are  important,  perhaps 
the  one  which  distinguishes  the  operating  room  "genius,"  so 
to  speak,  from  the  others  is  the  power  to  think,  plan,  and  work 
logically,  consistently,  and  methodically.  You  will  say  that  this 
power  is  an  asset  in  any  walk  of  life,  and  so  it  is,  but  it  is  use- 
ful here  to  the  utmost  degree,  and  its  lack  is  nowhere  of  more 
hindrance  than  in  the  operating  room.  This  not  only  applies 
while  the  operations  are  going  on  but  also  in  the  daily  routine 
of  the  department;  for  there  is  a  multiplicity  of  detail  in  this 
work  which,  if  muddled  by  cloudy  thought,  can  become  more 
of  a  squanderer  of  time,  energy,  and  service  than  any  other 
thing  we  can  think  of. 

These  are  all  desirable  qualifications.  You  have  some  of 
them,  and  perhaps  you  are  particularly  fortunate  and  have  all 
of  them;  but  at  any  rate  you  can  acquire  at  least  a  degree  of 
each  of  them,  and  you  must  do  so  if  you  wish  to  succeed  in  the 
operating  room  and  enjoy  the  work  there  as  you  should. 

2.  Division  of  Duties. — This  is  a  subject  upon  which  it  is 
useless  to  say  much  because  the  number  of  persons  on  a  staff 
is  determined  by  varying  and  numerous  circumstances,  and 
therefore  the  apportionment  of  the  work  will  be  different  in  all 
cases.  However,  the  principle  of  ^'division  of  labor"  should  be 
applied  as  minutely  as  possible,  particularly  in  a  large  operat- 
ing room  where  a  great  number  of  cases  are  done  in  one  session. 
By  ' '  division  of  labor ' '  we  mean,  of  course,  the  practice  whereby 
each  person's  w^ork  is  clearly  defined  for  her  so  that  she  is  held 
responsible  for  the  same  thing  at  all  times,  and  so  that  her  activi- 
ties do  not  overlap  those  of  the  others  on  the  staff.  How  this 
is  done  will  depend  upon  the  number  of  persons  on  the  staff, 
the  arrangement  of  the  operating  theater,  the  number  and  nature 
of  the  operations,  etc. ;  but  the  principle  should  be  to  aim  to 
have  as  many  persons  as  are  necessary  to  permit  division  of  the 
work  logically  up  to  the  point  where  each  one  has  only  the 
amount  of  work  to  do  which  she  can  get  done  with  reasonable 
ease.     More  work  than  this  for  each  person  causes  confusion. 


212  TEXTBOOK  OF  SURGICAL  NURSING 

delay,  and  gvnci-al  iiu't'tii'iciu'y ;  and  less  than  lliis  amount  is 
extravagaiU'O.  X'ariations  in  the  qualifications  and  capacities 
of  the  individuals  for  hard  work,  Avhether  they  are  graduate 
or  pupil  liurses,  orderlies,  etc.,  Avill  also  modify  this  division  of 
labor,  but  it  ^vill  not  affect  the  above  guiding  principle. 

3.  Discipline. — In  genei-al,  tlie  oi-ganization  of  an  efficient 
operating  room  staff:  as  to  authority,  system,  division  of  duties, 
thoroughness,  attention  to  detail,  promptness,  despatch,  and 
team  work  may  be  likened  to  that  of  the  Army.  There  must 
be  the  commanding  general  with  supreme  authority,  and  her 
staff  must  be  educated  to  corresponding  obedience.  Hospital 
discipline  in  general  is  often  likened  to  that  of  the  Army,  and 
the  operating  room  organization  should  embody  this  same  dis- 
cipline in  concentrated  form.  Emergencies  involving  life  and 
health  are  always  arising,  and  there  is  usually  no  time  for  '  *  rea- 
soning why"  when  orders  are  received.  If  each  one  knows  her 
duties,  has  been  given  the  proper  instructions  as  to  how  to  per- 
form them,  and  has  caught  the  spirit  of  "each  for  all,"  the 
system  will  do  the  rest. 

SUPPLIES 

(For  Sterilization  see  Chapter  XV) 

Our  next  step  is  to  provide  and  prepare  the  various  supplies 
and  odds  and  ends  which  it  will  be  necessary  to  keep  on  hand 
in  the  operating  room.  The  nurse  will  have  learned  about  and 
used  many  of  the  things  Ave  shall  need,  but  for  reference  pur- 
poses we  shall  record  here  a  list  of  standard  supplies  and  then 
go  into  detail  as  to  those  wdiich  are  likel}^  to  be  new  to  her  when 
she  begins  her  operating  room  training. 

1.  Adhesive  plaster  5.  Basins 

2.  Amputation  retractor  6.  Blankets 

3.  Aprons,  muslin  and  rubber  7.  Brushes,  nail 

4.  Bandages,  Esmarch  8.  Caps,  surgeon's  and  nurse's 

"  flannel  9.  Carrel-Dakin  outfit 

"  gauze  10.  Catheters 

"  muslin  11.  Cautery 

"  plaster  of  Paris          12.  Cotton 

"  starch  13.  Cover  for  instrument  stand 


EQUIPMENT  OF  THE  OPERATING  TPIEATER    213 


14. 

Culture  tubes 

38. 

Pads,  abdominal 

15. 

Dressings 

39. 

Pads,   table 

16. 

Drugs 

40. 

Pillows 

17. 

Gauntlets 

41. 

Rectal   tube 

18. 

Gauze 

42. 

Rubber  bands 

19. 

Glove  covers 

43. 

Rubber  dam 

20. 

Gloves,  rubber  and  cotton 

44. 

Rubber  sheets 

21. 

Gowns 

45. 

Rubber   tissue 

22. 

Hip  rest 

46. 

Rubber  tubing 

23. 

Hot  water  bottles 

47. 

Safety   pins 

24. 

Hypodermoclysis    outfit 

48. 

Salt  solution,  10  per  cent,  and 

25. 

Infusion   outfit 

infusion 

26. 

Inhaler,  ether 

49. 

Sandbags 

27. 

Instruments 

50. 

Sheets,  plain  and  laparotomy 

28. 

Irrigator 

51. 

Splints 

29. 

Irrigator  stand 

52. 

Stockings,   lithotomy 

30. 

Kelly  pad 

53. 

Stomach   tube 

31. 

Masks,   chloroform   and   ether 

54. 

Suits  for  surgeons 

32. 

Masks,  face 

55. 

Suture  material 

33. 

Mouth  gag 

56. 

Syringes 

34. 

Nail  cleaners 

57. 

Thermometers,  bath  and  clin- 

35. 

Needles,   hypodermic   and   ex- 

ical 

ploring 

58. 

Tongue   forceps 

36. 

Needles,  suture 

59. 

Tourniquets 

37. 

Packing,  gauze 

60. 

Towels,  plain  and  lithotomy 

We  shall  now  take  up  the  supplies  just  enumerated  in  the 
order  and  under  the  number  they  hold  in  the  list  and  discuss 
them  from  the  operating  room  standpoint. 

1.  Adhesive  Plaster. — This  needs  no  comment. 

2.  Amputation  Retractor. — Some  such  article  as  this  will  be 
necessary  in  the  absence  of  the  special  metal  instrument  for 
the  purpose,  and  it  will  be  used  to  hold  back  the  soft  parts 
while  the  bone  is  being  sawed  off  in  an  amputation  operation. 
It  is  made  from  strong  muslin  and  there  should  be  two  pat- 
terns— one  with  two  tails  for  use  on  the  femur  or  humerus,  and 
the  other  with  three  tails  for  the  two  bones  of  the  forearm  or 
the  lower  leg.  For  the  two-tailed  one  cut  the  muslin  24  x  24 
inches,  fold  double,  cut  half  way  up  through  the  middle  from 
one  edge,  and  stitch  in  all  edges.  (A  of  Fig.  38.)  For  the 
three-tailed  one  cut  the  muslin  30  x  24  inches,  fold  double,  cut 


214 


TEXTBOOK  OF  SURGICAL  NURSING 


in  thirds  half  avcIv  up  the  long  way,  and  stiteli  in  all  edges  (B 
of  Fig.  38). 

3.  Aprons. —  (a)  Muslin. — These  will  be  made  after  the 
pattern  of  the  ordinary  "buteher's"  apron,  and  may  be  used 
over  the  gown  or  suit  and  changed  for  each  operation.  (Fig. 
39.) 

(?;)  Fuhhcr. — These  may  be  purchased  read.y-made,  or  they 
are  very  easily  fashioned  from  a  piece  of  rubber  sheeting  by 
the  same  pattern  as  the  muslin  ones.  They  may  not  be  used 
in  routine  practice  but  there  should  be  several  on  hand  in  every 

operating  room  as  occasions  will  arise 
when  the  surgeon  or  the  nurse  will 
need  their  protection. 

4.  Bandages.  —  This  supply  will 
not  differ  from  that  which  the  nurse 
wall  have  learned  about  on  the  wards. 

5.  Basins. — A  good  assortment  of 
white  enameled  basins  should  be  on 
hand  for  both  sterile  and  unsterile 
usage.  The  familiar  kidney-shaped 
one  is  always  useful,  and  for  a  great 
variety  of  purposes ;  large  round 
ones  holding  a  gallon  wall  be  needed 
for  rinsing  hands  in  salt  solution,  etc., 
during  operations ;  smaller  ones  hold- 
ing a  pint,  perhaps,  will  be  service- 
able for  wound  or  dressing  solutions ;  long  narrow,  shallow  ones 
will  serve  for  sterilizing  in  antiseptic  solutions  instruments  which 
cannot  be  boiled.  The  exact  number  and  variety  of  each  can- 
not be  prescribed  but  the  supply  should  be  generous. 

Basins  for  use  upon  the  floor  about  an  operating  table  will 
also  be  needed.  Any  kind  Avill  do  but  a  great  deal  of  noise  wall 
be  saved  if  the  light-weight  "composition"  one  is  used,  espe- 
cialh''  in  the  ease  of  tile  or  cement  floor. 

6.  Blankets. — Plenty  of  blankets  will  be  needed,  and  there 
should  be  several  warm  ones  in  readiness  in  a  blanket  warmer, 
the  sterilizer,  or  upon  a  radiator  for  emergency  use  in  shock 
cases. 


3 

Fig.  38.  —  Amputation 
Ketractors.  a,  the  two- 
tailed  one  for  use  in  the 
amputation  of  one  bone;  B, 
the  three-tailed  one  for  use 
in  the  case  of  two  bones. 


EQUIPMENT  OF  THE  OPERATINCI  THEATER    215 

7.  Brushes,  Nail. — As  these  will  have  to  be  boiled  rex)eatedly 
a  very  plain  kind  should  be  used,  that  is,  the  backs  should  be 
unvarnished,  and  the  coarse  bristles  will  last  better  than  fine 
ones, 

8.  Caps. —  (a)  Surgeon's. — These  are  best  made  of  muslin 
and  may  be  merely  a  skull  cap  (A  of  Fig.  40)  or  they  may  be 
a  combination  of  cap  and  face  mask  (C  of  Fig.  40),  in  which 
case  it  is  better  to  use  a  thinner  material  as  the  heavier  one  may 


Fig.  39. — Muslin  Apron. 


be  too  warm  and  cumbersome.  The  surgeon  will,  as  a  rule, 
make  his  own  selection  of  design.  (&)  Nurse's. — These  are 
best  made  of  muslin  also,  and  any  design  that  will  cover  the 
hair  well  will  be  a  good  one  (B  of  Fig.  40)  and  the  combina- 
tion of  face  mask  and  cap  described  for  the  surgeon  (C  of  Fig. 
40)  may  also  be  used  by  the  nurse. 

9.  Carrel-Dakin  Outfit. — The  nurse  will  have  learned  all 
about  this  on  the  wards,  and  Chapter  XIX  gives  detailed  in- 
structions. The  only  equipment  that  need  be  kept  on  hand  in 
the  operating  room  will  be  the  wound  tubes,  the  vaseline  gauze, 
and  a  small  quantity  of  Dakin's  solution. 


216 


TEXTBOOK  OF  SURGICAL  NUESIiNG 


10.  Catheters. — These  will  not  often  be  used  in  the  operat- 
inji'  room  but  a  few  of  both  the  rublter  and  the  glass  ones  used 
on  the  wards  should  be  kept  on  hand. 

11.  Cautery. — There   are   several   kinds   of   cautery  which 


Fig,  40. — Operating  Caps.  A,  simple  skull  cap  for  the  surgeon;  B, 
nurse's  cap;  C,  combination  cap  and  mask  suitable  for  either  surgeon  or 
nurse  (see  directions  for  making  cap  C  on  page  222). 

are  described  in  Chapter  XV,  pages  242-245,  under  "Steriliza- 
tion, ' '  as  the  cautery  is,  of  course,  a  sterilizing  agent. 

12.  Cotton. — Both  the  absorbent  and  the  non-absorbent 
cotton  used  on  the  wards  should  be  on  hand. 

13.  Cover  for  Instrument  Stand.— This  will  be  a  slip  cover, 
simply  a  long  narrow  bag  (see  Fig.  24,  page  199),  which  is  de- 


EQUIPMENT  OF  THE  OPERATING  TIIEATER    217 


%'';/f\ 


signed  to  envelop  the  instrument  stand  which  extends  across  the 
table  for  operations.  This  bag  should  be  made  long  enough  to 
reach  well  downward  toward  the  base  when  the  stand  is  ex- 
tended to  its  highest  capacity,  as  it  will  then  enable  the  instru- 
ment passer  to  adjust  the  height  of  the  table  sterilly  at  all  times 
and  will  furnish  the  simplest  means  of  covering  the  unsterile 
standard.     It   should  be   made   of   strong  ^,^ 

muslin,  and  the  size  of  it  will  depend,  of 
course,  upon  the  size  of  your  particular 
table. 

14.  Culture  Tubes. — Cultures  will  fre- 
quently be  taken  from  wounds  and  a  few 
tubes  should  always  be  ready  (Fig.  41). 
Make  a  cotton  swab  on  a  long  wooden  or 
wire  applicator ;  put  this  into  a  small  glass 
test  tube,  allowing  the  end  to  project  about 
half  an  inch,  plug  the  tube  loosely  with 
cotton,  and  then  put  it  into  a  larger  test 
tube  and  plug  this  with  cotton,  and  ster- 
ilize. The  outer  tube  keeps  the  inner  one 
sterile  so  that  it  may  be  handled  by  a  ster- 
ile person,  and  the  inner  one  is  for  the  re- 
ception of  the  swab  after  the  culture  has 
been  taken. 

15.  Dressings. — The  assortment  and  de- 
signs used  in  the  wards  will  probably  apply 
to  the  operating  room.  These  will  include 
one  or  two  sizes  of  small  gauze  wound 
sponges  or  "wipes";  one  or  two  sizes  of 

larger  flat  gauze  wound  dressings;  "fluffs"  or  1-yard  pieces  of 
gauze  folded  together  loosely  for  use  on  wounds  from  which 
there  is  likely  to  be  much  drainage ;  and  perhaps  a  long  narrow 
.rolled  gauze  dressing  which  can  be  applied  to  a  wound  of  the 
extremities  in  bandage  fashion. 

16.  Drugs. — The  following  list  represents  the  drugs  most 
likely  to  be  called  for: 


Fig.  41. — Culture 
Tubes.  A,  tube  con- 
taining a  culture  me- 
dium; B,  tubes  con- 
taining swab  for  tak- 
ing specimen  of  pus 
from  the  wound. 


Adrenalin 
Albolene,   liquid 


Alcohol 
Argyrol 


218 


TEXTBOOK  OF  SURGICAL  NURSING 


Aristol  powder 

Aromatic  spirit  of  ammonia 

Atropine    (hypodermie) 

Benzine 

Bichloride  of  mercury 

Boric  acid,  powder  and  crystals 

Caffeine   (hyiDoderniic) 

Camphor  in  oil  or  ether 

(hypodermic) 
Carbolic  acid 

Carbonate  of  soda  (washing  soda) 
Chloroform 
Cocaine 

Codeine  (hypodermic) 
Collodion 
Dakin's  solution 
Ether 

Ethyl  chloride 
Formalin 


Glycerine 

Green  soap 

Hyoscine    (hypodermic) 

Iodine,  tincture 

Lime,  chloride 

Lubricant   (vaseline,  K-Y,  etc) 

Morphine    (hypodermic) 

Nitrous  oxide 

Novocain 

Olive  oil 

Oxygen 

Peroxide  of  hydrogen 

Silver  nitrate,  solution  and 

"stick" 
Sodium  chloride 
Strychnine  (hypodermic) 
Talcum  powder 
Vaseline 
Water,  distilled 


17.  Gauntlets. — These  will  simply  be  loose  muslin  sleevelets 
which  will  reach  from  well  above  the  elbow  to  the  hand.  They 
will  be  used  Avith  the  short-sleeved  suits  and  gowns  in  com- 
bination with  the  muslin  apron  (Paragraph  No.  3)  and  will  be 
kept  in  place  either  with  a  rubber  band  or  a  safety  pin. 

18.  Gauze. — See  "Dressings"  (Paragraph  No.  15). 

19.  Glove  Covers. — Though  not  necessary,  these  covers  will 
be  a  great  convenience  and  they  are  very  simple  to  make.  Cut 
a  piece  of  muslin  about  12  x  31  inches,  hem  the  ends,  fold  each 
end  to  the  middle  of  the  piece,  and  stitch  the  sides  so  as  to  make 
a  double  envelope  (Fig.  42)  into  which  the  gloves  may  be 
slipped  separately;  then  fold  through  the  middle  into  a  com- 
pact parcel. 

20.  Gloves. —  (a)  Rubber. — There  are  numerous  kinds  of 
rubber  gloves  on  the  market  and  the  one  you  provide  will  de- 
pend upon  the  choice  of  the  surgeon.  They  are  made  in  many 
sizes,  so  everyone  can  be  well  fitted,  and  it  is  important  that 
this  be  done  for  too  tight  a  glove  will  be  very  uncomfortable 
and  too  large  a  one  will  be  a  hindrance.     Many  gloves  should 


EQUIPMENT  OF  THE  OPERATING  THEATER    219 

be  kept  in  reserve  as  they  do  not  last  long  and  they  should  not 
be  used  except  when  in  good  condition. 

(&)   Cotton. — These  are  not  often  used  but  occasionally  they 
are  slipped  over  the  rubber  ones  when  it  is  difficult  to  handle 


1   ill 

i 

'.         ^      : 

•    *: 

J         ■ -= 

Fig.  42. — Glove  Cover. 


such  parts  as  the  intestines,  the  breast,  etc.,  as  the  rubber 
gloves  are  likely  to  slip  awkwardly  on  these  parts.  Any  good 
cotton  glove  will  answer  the  purpose,  but  relatively  large  ones 
must  be  provided  as  they  shrink  considerably  in  sterilization. 


220  TEXTBOOK  OF  SURGICAL  NURSING 

21.  Gowns. — These  should  be  made  of  heavy  "twilled" 
muslin  and  several  sizes  should  be  provided.  They  must  be 
made  to  close  in  the  back,  and  tape  strings  that  may  be  tied  are 
better  than  buttons  for  closing  them  as  they  withstand  the  wear 
and  tear  of  the  laundry  better.  They  will  have  either  long  or 
short  sleeves,  the  long  ones  l)eing  used  when  the  gown  is 
changed  between  operations  and  the  short  ones  when  the  gaunt- 
lets (Paragraph  No.  17)  and  aprons  (Paragraph  No.  3)  are 
used.  The  chief  point  to  notice  about  the  gowns  is  that  the 
long  sleeves  are  long  enough  to  reach  well  down  to  the  hand  so 
that  they  may  be  securely  tucked  under  the  rubber  gloves,  and 


A  :b 

Fig.  43. — Two  Types  of  Hip  or  Pelvic  Rest.  A,  metal  design  which  is 
especially  suitable  in  the  application  of  a  plaster  of  Paris  hip  spica ;  B,  a 
simple  wooden  block  which  will  be  better  suited  than  A  for  use  in  applying 
a  hip  spica  bandage  to  a  conscious  patient,  as  it  will  be  long  enough  to 
reach  across  the  patient 's  body  and  thus  to  balance  him  comfortably, 
whereas  the  metal  one  is  narrow,  is  too  uncomfortable  for  a  conscious 
patient,  and  usually  requires  an  assistant  to  keep  the  patient  balanced 
upon  it. 

that  the  short  ones  reach  well  to  the  elbow  so  that  they  may  be 
kept  securely  within  the  gauntlet. 

22.  Hip  Rest. — The  nurse  will  have  learned  about  the  uses 
of  the  hip  rest  (Fig.  43)  on  the  ward  and  they  will  be  the  same 
in  the  operating  room,  namely,  for  convenience  in  applying  hip- 
spica  bandages. 

23.  Hot  Water  Bottles. — These  will  sometimes  be  needed 
for  patients  in  shock. 

24.  Hypodermoclysis  Outfit. — This  will  be  the  same  as  the 
one  used  on  the  ward. 

25.  Infusion  Outfit. — This  also  will  have  been  learned  about 
on  the  ward. 

26.  Inhaler. — The  surgeon  or  the  anesthetist  will  usually 
decide  upon  the  particular  variety  to  be  provided. 

27.  Instruments. — This  subject  will  be  best  learned  by  the 


EQUIPMENT  OF  THE  OPERATING  THEATER    221 


actual  handling  of  the  instruments  in  the  operating  room, 
though  we  discuss  the  subject  for  the  benefit  of  the  nurse  who 
may  need  to  prepare  for  instrument  passing  in  Chapter  XVII, 
and  many  suggestions  are  included  in  the  discussions  of  the 
various  operative  procedures  in  Chapters}  IV  to  XI. 

28.  Irrigator. — There  are  many  kinds  (Fig.  96,  page  326) 
and  no  one  is  necessarily  bet- 
ter suited  to  operating  room 
purposes  than  any  other.  The 
glass  one  is  very  satisfactory 
as  the  contents  are  visible,  but 
it  is  more  troublesome  to  care 
for  than  the  enameled  metal 
one. 

29.  Irrigator  Stand. — This 
will  be  needed,  as  on  the 
wards,  for  wound  irrigations, 
infusions,  etc.,  and  the  design 
is  not  important  (Fig.  44). 

30.  Kelly  Pad. — The  nurse 
will  have  become  familiar  with 
this  type  of  pad,  either  under 
this  name  or  some  other,  on 
the  wards,  and  its  use  in  the 
operating  room  will  be  pointed 
out  under  "Operative  Posi- 
tions and  Draping"  in  Chap- 
ter XVI.  An  improvised  one 
made  from  a  newspaper  and  a  rubber  sheet  is  illustrated  in  Fig. 
153,  page  413. 

31.  Masks,  Chloroform  and  Ether. — The  special  variety  to 
provide  will  usually  be  determined  by  the  surgeon  or  the  an- 
esthetist. 

32.  Masks,  Face. — There  are  many  designs  for  simple 
masks  which  merely  cover  the  mouth  and  nose  and  the  illus- 
trations in  Fig.  45  show  representative  designs  for  this  article. 
Designs  A  and  B  consist  merely  of  several  layers  of  gauze  or  of 
one  heavy  piece  with  tapes  sewed  to  the  corners  for  tying  around 


Fig.  44. — Two  Types  of  Irrigator 

Stand. 


222 


TEXTBOOK  OF  SURGICAL  NURSING 


tlio  head  and  neck.  Design  C  is  merely  a  pieee  of  gauze  cut  30 
inches  square,  folded  diagonally  by  turning  two  diagonally  op- 
posite corners  to  the  center  of  the  piece  and  continuing  to  fold 
in  this  direction  till  the  strip  is  5  or  G  inches  in  width.     It  is 


Fig.  45. — Face  Masks.  Aj  several  layers  of  gauze  stitched  together,  and 
having  tape  strings  attached  to  each  corner  for  tying  around  the  head  and 
neck ;  B,  made  similarly  to  A ;  C,  piece  of  gauze  folded  as  described  in  Para- 
graph No.  32 ;  D,  made  either  of  one  layer  of  heavy  gauze  or  of  several 
layers  of  thinner  gauze,  with  tapes  attached  for  tying  in  place  as  illus- 
trated in  C  of  Fig.  40,  page  216. 


adjusted  by  placing  the  middle  of  it  over  the  face,  twisting  the 
ends  till  it  fits  neatly,  and  then  tying  over  the  crown  of  the 
head.  Mask  D  of  the  illustration  is  the  outline  of  the  one  which 
is  shown  adjusted  to  the  wearer  in  C  of  Fig.  40. 

33.     Mouth  Gag. — There  are  many  designs  from  which  to 


EQUIPMENT  OF  THE  OPERATING  THEATER    223 

select,  and  two  representative  types  are  illustrated  in  Fig.  21, 
page  186. 

34.  Nail  Cleaners. — Any  kind  that  can  be  boiled  will  do, 
but  there  is  probably  nothing  better  than  the  simple  orange 
stick. 

35.  Needles. — A  plentiful  supply  of  hypodermic  and  ex- 
ploring needles  will  be  needed,  including  the  long,  slender,  hypo- 
dermic needles  which  will  be  considerably  in  demand  for  local 
anesthesia. 

36.  Needles,  Sutiire. — These  are  properly  classified  as  in- 
struments and  it  will  be  assumed  that  the  nurse  has  learned 
the  varieties  during  the  course  of  her  practical  training. 

37.  Packing. — Plenty  of  gauze  packing  of  assorted  widths 
from  %  inch,  or  even  less,  up  to  2  inches  should  be  in  readi- 
ness at  all  times.  The  nurse  will  have  learned  how  to  make  this 
on  the  wards.  The  larger  sizes  should  be  made  in  lengths  of  5 
yards  or  more,  as  w^hen  packing  of  this  width  is  used  in  the 
operating  room  a  large  quantity  will  be  needed  and  in  most 
cases  it  will  be  very  important  that  it  be  in  one  uncut  piece. 

•  38.  Pads,  Abdominal. — These  pads  are  used  for  blocking 
off  the  operative  field  in  abdominal  operations,  and  several  sizes 
and  shapes  will  be  needed  (Fig.  46).  Pads  A,  B,  and  C  of  the 
illustration  are  made  of  from  6  to  10  layers  of  gauze  carefully 
turned  in  and  sewed  at  the  edges,  and  with  a  piece  of  strong 
tape  firmly  sewed  to  one  corner  so  that  they  may  be  secured  in 
some  way  on  the  outside  of  the  wound  to  prevent  their  being 
lost  in  the  abdominal  cavity.  In  some  cases  it  may  be  the  cus- 
tom to  sew  a  heavy  iron  ring  to  the  end  of  the  tape.  This  ring 
is  conveniently  pinned  to  the'  draping  sheet  or,  because  of  its 
weight  and  the  report  it  gives  if  the  pad  accidentally  falls  to 
the  floor,  it  is  a  very  satisfactory  means  of  keeping  track  of  the 
otherwise  somewhat  elusive  pad.  In  other  cases  the  tape  will 
be  fastened  to  the  sheet  with  a  safety  pin  or  clamp,  or  it  will 
simply  be  marked  by  the  attachment  of  an  artery  clamp  to  it. 
Pad  D  is  about  1  yard  long,  5  inches  wide,  and  8  or  10  layers 
thick.  It,  also,  will  have  a  tape  attached,  and  it  should  be  rolled 
into  the  shape  of  a  roller  bandage  because  it  will  be  more  con- 
venient to  handle  in  this  form.     Pad  E  of  the  illustration  is 


224 


TEXTBOOK  OF  SURGICAL  NURSING 


especially  designed  for  use  in  the  removal  of  the  appendix.  It 
will  be  made  about  6  inches  long,  4  inches  wide,  and  6  layers 
thick ;  it  will  be  split  half  the  way  up  from  the  middle  of  one 


Fig.  46. — Abdominal  Pads.  A,  B,  and  C,  are  made  of  gauze  in  dimen- 
sions of  2x6  inches^  4x10  inches,  and  10  x  10  inches  respectively,  and 
should  be  from  6  to  10  layers  thick;  B,  is  1  yard  long,  5  inches  wide,  and 
10  layers  thick;  E,  is  6  inches  long,  4  inches  wide,  and  6  layers  thick,  and  is 
split  into  two  tails  at  one  end  for  use  in  folding  about  the  appendix  during 
its  removal. 


end  and  will  be  finished  about  the  edges  like  the  others.  This 
pad  will  not  need  a  tape  because  it  will  be  used  only  on  the  sur- 
face of  the  wound. 

39.     Pads  for  the  Operating  Table. — The  table  must  always 
be"  covered  with  a  soft  pad.     Often  this  will  be  supplied  with 


EQUIPMENT  OF  THE  OPERATING  THEATER    225 

the  table  by  the  manufacturer,  but  one  is  easily  made  by  cover- 
ing a  folded  blanket  or  any  similar  material  with  rubber  sheet- 
ing. The  rubber  sheeting  should  never  be  omitted  but  it  should 
be  covered  with  a  muslin  sheet  before  a  patient  is  placed  upon  it. 

40.  Pillows.— For  all  operating  room  purposes  the  hair  pil- 
low is  better  than  any  other.  There  will,  of  course,  be  the 
ordinary  ones  for  the  patient's  head,  and  uses  will  be  pointed 
out  later  for  several  smaller  sizes — to  fit  under  the  back,  the 
knees,  and  the  patient's  head  in  some  unusual  positions. 

41.  Rectal  Tube. — This  will  sometimes  be  needed  for  stimu- 
lating enemata,  etc. 

42.  Rubber  Bands. — There  should  be  a  good  assortment  of 
rubber  bands  as  various  sizes  will  be  used  occasionally  for  drains. 
Also,  when  the  muslin  gauntlets  are  used  a  light-weight  band 
about  the  arm  will  be  very  convenient  for  keeping  them  in 
place. 

43.  Rubber  Dam. — This  is  a  soft  gum  rubber  which  is  made 
in  sheets  of  various  sizes,  and  it  is  used  chiefly  for  drains,  usually 
the  ''cigarette"  drain.  As  this  will  be  made  up  after  it  is 
sterilized  it  will  be  taken  up  again  under  ' '  Instrument  Passing ' ' 
in  Chapter  XVII,  and  the  sterilization  of  it  is  taken  up  on 
page  249. 

44.  Rubber  Sheets. — A  generous  supply  of  these  sheets 
should  be  provided,  and  they  should  be  used  unstintingly  to 
protect  both  patients  and  operating  table  in  cases  where  there 
is  likely  to  be  fluid  of  any  kind  spilled  about.  A  heavy  gum 
rubber  sheeting  is  the  softest  kind  and  is  more  agreeable  to  use 
and  easier  to  cleanse  than  any  other,  but  it  is  relatively  ex- 
pensive. However,  it  is  about  the  only  kind  that  should  be 
UiSed,  as  those  which  are  made  partially  of  cloth  cannot  be  kept 
clean  enough  for  operating  room  purposes.  Pieces  1  yard 
square  will  be  the  most  serviceable. 

45.  Rubber  Tissue. — This  will  be  purchased  in  thin  sheets 
of  about  one  square  yard  each.  It  is  useful  for  many  purposes 
such  as  covering  dressings,  for  drains,  etc.  Its  preparation  for 
use  is  discussed  on  page  250,  and,  under  "Drains,"  in  Chapter 
XVII,  page  310. 

46.  Rubber  Tubing. — The   operating  room  should  possess 


226  TEXTBOOK  OF  SURGICAL  NURSING 

a  good  supply  of  all  sizes  of  rubber  tubing  for  it  is  used  for 
many  different  purposes. 

47.  Safety  Pins. — Many  of  these,  of  course,  are  always 
needed. 

48.  Salt  Solution. —  (a)  Concentrated. — For  purposes  of  ir- 
rigation or  of  rinsing  gloves  during  the  operation  the  normal 
salt  solution  {0S)%)  made  from  ordinary  salt  and  the  filtered 
Avater  from  the  water  sterilizer  will  answer.  A  convenient  way 
to  provide  this  is  to  sterilize  the  salt  in  concentrated  solution, 
10%  for  instance,  in  flasks  holding  enough  for  one  day's  use. 
The  proper  amount  of  this  solution  is  easily  added  to  water 
when  needed,  2y->  ounces  of  the  10%  solution  in  a  quart  of  water 
making  the  normal  solution  nearly  enough  for  purposes  of  irri- 
gation or  rinsing.  (&)  For  Infusions. — For  intravenous  in- 
fusions a  more  refined  solution  must  be  made  because  this  is 
injected  directly  into  the  blood  stream  where  any  but  the  ac- 
curately normal  solution  can  cause  serious  damage.  Distilled 
water  may  be  used,  but  clean  tap  water  is  not  objectionable; 
chemically  pure  sodium  chloride  is  advisable,  though  good  com- 
mon table  salt  will  do;  and  the  0.9%  solution  must  be  accurately 
mixed. 

The  drug  market  supplies  salt  specially  prepared  for  the  in- 
fusion solution,  and  in  some  cases  the  potassium  chloride  and 
the  calcium  chloride  will  be  included,  but  the  chemically  pure 
sodium  chloride  is  extensively  used  alone  and,  as  stated  above, 
common  table  salt  answers  very  well.  The  manufacturer  will 
enclose  directions  for  mixing  his  particular  product,  but  where 
the  sodium  chloride  alone  is  used  the  proper  proportion  will  be 
124  grains  of  salt  to  one  quart  of  solution.  The  nurse  should 
remember  that  the  amount  of  salt  is  i)resci"ibed  by  weight  and 
she  will  not  attempt,  therefore,  to  measure  it  with  a  spoon  or 
any  other  such  inexact  measure,  because  it  would  be  a  rare  case 
indee(i  in  which  a  pharmacist  could  not  be  found  to  weigh  it 
for  her.  After  the  salt  has  been  dissolved  in  the  water  the 
solution  must  be  filtered  through  fine  filter  paper  a  sufficient 
number  of  times  to  make  it  perfectly  clear,  and  then  it  should 
be  put  into  quart-size  glass  flasks  for  sterilization,  the  flasks 
being  very  securely  stopped  with  plugs  of  non-absorbent  cotton 


EQUIPMENT  OP  THE  OPERATING  THEATER    227 

covered  with  gauze  and  tied  well  down  over  the  mouth  of  the 
flask.  The  cleanest  and  easiest  practice  in  making  this  solution 
is  to  filter  it  directly  from  one  flask  to  another  each  time. 

49.  Sandbags. — For  the  adjustment  of  the  patient's  posi- 
tion upon  the  table  it  will  often  be  necessary  to  have  sandbags 
of  various  sizes.  The  sand  for  these  bags  should  be  fine  and 
clean,  sea  sand  being  the  best ;  the  bags  should  be  made  of  heavy 
canvas  or  "ticking";  and  this  should  be  covered  with  strong 
rubber  sheeting.  Care  should  be  taken  not  to  fill  them  too 
full,  as  a  slightly  flexible  bag  is  more  adaptable  than  a  solid  one. 

50.  Sheets. —  (a)  Plain  Muslin.— A  generous  supply  of 
large  heavy  muslin  sheets  must  be  on  hand  for  both  sterile 


Fig.  47. — Laparotomy  Sheet.  This  is  simply  a  large  muslin  sheet  with, 
an  oblong  opening  cut  in  the  center.  The  size  of  this  opening  should  not 
be  less  than  4x8  inches,  and  much  larger  openings  are  often  preferred. 

and  unsterile  purposes.  (&)  Laparotomy. — Another  type  of 
sheet  which  is  very  easily  made  and  which  is  a  very  convenient 
article  is  the  "laparotomy"  sheet  (Fig.  47).  This  is  merely  a 
muslin  sheet  which  is  long  enough  to  cover  the  entire  table  and 
which  has  an  opening  about  4x8  inches  or  larger  cut  in  the  cen- 
ter of  it — this  must,  of  course,  be  durably  bound  with  tape. 
This  sheet  will  be  useful  for  a  great  many  operations,  and  we 
shall  point  out  its  uses  under  "Operative  Positions  and  Drap- 
ing" in  Chapter  XVI. 

51.  Splints. — See  suggested  varieties  in  Chapter  VII,  under 
the  discussion  of  "Fractures." 

52.  Stockings,  Lithotomy. — For  operations  in  the  lithotomy 
position  (Fig.  74,  page  279)  it  is  desirable  to  have  large  muslin 
stockings  which  will  slip  over  the  patient's  feet  and  the  table 
fixture  loosely  and  extend  well  over  the  patient's  abdomen  and 


228  TEXTBOOK  OF  SURGICAL  NURSING 

down  over  the  side  of  the  table.  Any  iitirse  can  dcsioii  a  stock- 
ing suitable  for  this  ])urpose,  as  the  cliief  re((uisite  is  that  it 
be  of  generous  size. 

53.  Stomach  Tube. — This  will  be  needed  for  an  occasional 
lavage. 

54.  Suits. — Hospital  furnishing  houses  will  supply  these  op- 
erating suits  which  are  made  of  a  heavy  "twilled"  muslin. 
They  will  have  short  sleeves,  and  the  apron  (Paragraph  No.  3) 
and  gauntlets  (Paragraph  No.  17),  or  the  gown  (Paragraph 
21)  will  be  used  Avith  them. 

55.  Suture  Material. — We  shall  give  here  only  general  in- 
formation about  suture  materials,  for  it  will  be  the  exception 
rather  than  the  rule  that  the  nurse  will  be  called  upon  to  pre- 
pare them  because  factories  supply  them  so  convenient!}^  that 
most  hospitals  purchase  them  ready  for  use.  In  Chapter  XV, 
however,  under  "Sterilization,"  Ave  record  various  processes  in 
detail  for  the  benefit  of  those  who  may  at  some  time  need  to 
refer  to  them. 

Likewise,  and  for  a  corresponding  reason,  w^e  shall  speak  only 
in  a  general  way  here  of  the  uses  of  suture  material  and  leave 
the  details  for  the  discussion  of  "Instrument  Passing"  in  Chap- 
ter XVII. 

Substances  used  for  sewing  wounds  are  of  two  classes :  Those 
which  are  al)Sorl)able  by  the  tissues,  and  those  which  are  non- 
ahsorhahle  and  which  must,  with  a  few  exceptions,  be  removed 
as  soon  as  the  wound  is  nearly  enough  healed  to  hold  together 
without  them. 

The  absorbable  suture  materials  are  catgut  and  kangaroo 
tendon. 

Catgut  is  made  from  the  intestines  of  animals,  usually  the 
sheep,  and  consists  of  a  strip  of  the  submucous  coat  which  has 
been  twisted,  rope  fashion,  into  a  fairly  smooth  thread,  and  then 
dried,  cut  into  standard  lengths,  and  sterilized.  This  is  ordi- 
narily called  "plain  catgut."  It  is  usually  absorbed  by  the 
tissues  within  5  to  10  days.  To  make  it  more  resistant  to  ab- 
sorption this  plain  catgut  is  treated  with  chromic  acid  which 
hardens  it,  and  then  we  get  a  suture  that  Avill  hold  fast  as  long 
as  20  days  or  more,  depending  upon  the  length  of  time  it  is 


EQUIPMENT  OF  THE  OPERATING  THEATER    229 

subjected  to  the  hardening  action  of  the  chromic  acid.  This 
suture  is  called  "chromic"  catgut. 

The  market  usually  supplies  the  catgut  in  seven  sizes  num- 
bered 000,  00,  0,  1,  2,  3,  and  4,  the  No.  000  being  about  the 
weight  of  No.  60  sewing  cotton  and  the  No.  4  about  like  that  of 
the  average  wrapping  twine  used  in  stores. 

Kangaroo  tendon  is  made  from  the  tendon  of  the  kangaroo's 
tail  in  a  manner  similar  to  that  for  catgut.  It  is  usually  some- 
what more  resistant  to  absorption  than  chromic  catgut.  It  is 
manufactured  in  several  weights. 

Catgut  is  by  far  the  more  frequently  used  of  these  materials, 
the  great  majority  of  wounds  being  sewed  together  with  it,  and 
practically  all  bleeding  vessels  tied  with  it. 

The  common  non-absorbable  suture  materials  are :  Horsehair, 
line7i  thread,  silk  thread,  silkworm  gut,  silver  and  aluminum- 
hronze  wires,  and  metal  ^' clips." 

Horsehair  is  simply  the  long  hair  from  the  horse's  tail  which 
is  easily  cleansed  and  sterilized.  It  is  usually  black  in  color 
when  purchased  ready  for  use,  but  when  not  naturally  black 
it  is  dyed  to  make  it  more  clearly  visible  against  the  white  drap- 
ing towels  and  the  patient's  skin. 

Silk  and  linen  thread  are  familiar  to  every  nurse.  They  are 
usually  dyed  black  for  the  reason  given  for  horsehair.  Silk 
is  used  chiefly  as  a  suture  for  the  skin,  and  linen  is  employed 
almost  exclusively  on  the  intestine  and  stomach.  Silk  is  most 
frequently  used  without  having  been  treated  in  any  way  be- 
yond sterilization,  but  sometimes  it  is  saturated  with  paraffine 
or  albolene  (see  sterilization  of  silk  thread,  on  page  260).  Linen, 
also,  is  much  used  plain,  but  perhaps  the  favorite  form  is  the 
celluloid  linen,  which  means  simply  the  linen  thread  which  has 
been  saturated  with  a  preparation  of  celluloid.  A  common 
brand  of  this  kind  of  linen  thread  is  known  as  ' '  Pagenstecher. ' ' 
The  paraffine  and  the  celluloid  in  these  cases  serve  the  purpose 
of  making  the  suture  less  likely  to  disintegrate  when  used  in 
parts  from  which  it  is  never  removed ;  and  the  albolene  serves 
chiefly  as  a  lubricant,  particularly  in  the  removal  of  the  sutures. 
These  threads  may  be  purchased  in  a  variety  of  weights. 

The  student  will  recall  that  silk  and  linen  were  classified 


230  TEXTBOOK  OF  SURGICAL  NURSING 

above  as  non-absorbable  materials,  and  may  wonder  how  these 
"foreign  bodies"  can  sometimes  be  left  permanentl}'^  in  such 
parts  as  the  intestines,  for  instance;  but  it  so  happens  that 
nature  is  capable  of  accommodating  herself  to  a  few  such  in- 
vasions b}''  either  encapsulating  the  invader  so  as  to  shield  the 
more  sensitive  tissues  from  its  irritating  effect,  by  eventually 
disintegrating  it,  or  by  sloughing  it  out. 

Silkworm  gut  is  made  by  draAving  out  into  a  thread  the  duc- 
tile sac  which  the  silkworm  has  just  prepared  from  which  to 
spin  his  cocoon.  This  is  naturally  white,  but  it  is  usually  dyed 
black  before  it  is  prepared  for  use.  Silkworm  gut  is  a  rela- 
tively strong  suture  material  and  is  therefore  used  as  a 
*  *  through-and-through "  suture  to  hold  together  large  abdom- 


FiG.  48. — Lithotomy  Tovv-el.  Made  of  heavy  muslin  about  2  yards  long 
and  28  inches  wide.  The  opening  in  the  center  is  about  3  or  4  inches  in 
diameter.    See  use  of  this  towel  in  Fig.  74,  page  279. 

inal  wounds  or  any  wound  in  which  there  is  likely  to  be  much 
tension  during  the  healing  period.  It  is  supplied  in  several 
weights. 

Silver  and  aluminimi-'bronze  wire  are  used  to  suture  together 
the  fragments  or  ends  of  broken  bones  chiefly. 

Metal  clips  are  made  of  silver  or  some  other  non-corroding 
soft  metal,  and  they  are  used  for  skin  wounds  and  occasionally 
for  ligating  blood  vessels.  The  clip  which  the  nurse  will  be 
most  likely  to  see  in  hospitals  is  the  one  called  the  "Michel" 
skin  clip. 

56.  Syringes. — There  are  innumerable  types  of  syringe,  and 
the  nurse  will  have  learned  on  the  wards  the  kinds  Avhich  are 
in  common  use  for  hypodermics,  aspirations,  irrigations,  etc., 
and  these  three  classes  will  cover  the  usual  needs  for  the  oper- 
ating room. 


EQUIPMENT  OP  THE  OPERATING  THEATER    231 

57.  Thermometers. — The  clinical  thermometer  will  be 
rarely  used,  but  the  bath  thermometer  should  always  be  ready 
to  use  for  all  irrigations,  infusions,  etc. 

58.  Tongue  Forceps. — The  surgeon  or  anesthetist  will  de- 
cide upon  the  variety  to  be  provided,  but  three  kinds  are  illus- 
trated in  Fig.  20,  page  185. 

59.  Tourniquets. — There  are  numerous  varieties  but  a  very 
simple  and  extensively  used  one  consists  of  a  piece  of  heavy 
rubber  tubing  which,  is  long  enough  to  be  tied  about  the  limb, 
or,  it  is  often  secured  by  means  of  a  strong  clamp. 

60.  Towels. —  (a)  Plain. — The  only  point  to  mention  about 
these  towels  is  that  they  be  of  some  soft,  absorbent  material 
which  launders  well.  Perhaps  the  best  material  is  that  which 
is  known  commercially  as  "bird's-eye  cotton."  A  linen  or 
other  smooth-surface  towel  will  be  found  unsatisfactory  because 
it  will  not  stay  in  place  well;  instruments  slide  upon  it;  and 
stains  of  blood,  iodine,  etc.,  are  not  easily  removed  from  it. 
(&)  Lithotomy. — This  is  not  a  necessity,  as  a  sheet  or  the  wound 
towels  may  be  used  instead,  but  it  is  a  great  convenience  and 
it  is  so  easily  made  that  we  recommend  its  inclusion  in  the 
equipment.  It  consists  merely  of  a  piece  of  muslin  about  two 
yards  long  and  28  inches  wide  in  the  center  of  which  an  opening 
3  or  4  inches  in  diameter  is  made  (Fig.  48).  This  is  used  for 
draping  patients  in  the  lithotomy  position,  as  illustrated  in 
Fig.  74,  page  279. 


CHAPTER  XV 

OPERATING   ROOM    STERILIZATION 

The  subject  of  bacteriolog}'  is  of  tremendous  concern  in  rela- 
tion to  operating-  room  sterilization  and,  as  "we  have  said  previ- 
ously, the  pupil  should  have  studied  it  before  taking  up  the  op- 
erating room  course.  However,  those  students  who  have  not 
yet  covered  the  subject  -will  find  material  upon  it  in  Chapter  I, 
and  we  shall  review  briefly  here  a  few  of  the  more  important 
terms  which  have  a  bearing  upon  the  contents  of  this  chapter. 

DEFINITIONS 

Septic. — When  we  say  that  a  wound  is  septic  we  are  using 
a  general  term  which  means  that  it  is  under  the  actively  de- 
structive influence  of  bacteria  of  some  kind,  and  the  word  car- 
ries with  it  a  special  emphasis  upon  the  decomposition  caused 
by  the  bacteria  and  its  effects.  The  noun,  sepsis,  then,  would 
mean  the  state  or  condition  of  being  septic. 

Infection. — This  is  a  term  that  is  hard  to  differentiate  from 
sepsis,  for  when  we  say  that  a  wound  is  infected  we  mean,  as 
we  would  if  we  called  it  septic,  that  it  is  inhabited  by  bacteria 
w^hich  are  multiplying  within  it,  are  feeding  upon  it,  and  are, 
therefore,  destroying  its  health.  In  common  parlance  we  use 
the  terms  interchangeably,  however,  and  there  is  perhaps  no 
important  difference  between  them  except,  as  mentioned  above, 
sepsis  does  bear  more  of  a  reference  to  the  products  of  infection 
and  also  to  their  effects.  The  term  infection  is  also  used  in  the 
sense  of  its  being  the  act  or  process  by  which  the  Avound  is  con- 
taminated with  bacteria,  and  in  the  sense  of  its  being  the  bac- 
teria themselves  at  work  in  the  wound.  The  use  of  bacteria- 
laden  hands  or  instruments,  for  instance,  in  a  wound  would  be 
the  act  of  infection,  and  the  resultant  growth  of  the  bacteria 
in  the  wound  would  be  the  infection  itself. 

232 


OPERATING  ROOM  STERILIZATION  233 

Aseptic. — The  term  septic,  then,  with  a-,  which  means  not, 
prefixed,  will  mean  not  septic,  or  free  from  sepsis;  and  the 
phrase,  aseptic  surgery,  will  signify  surgery  done  in  such  a 
way  as  to  prevent  bacteria  from  gaining  access  to  a  wound. 

Antiseptic. —  This  same  term,  with  another  prefix,  anti-, 
which  means  against,  will  then  mean  something  that  is  opposed 
to  sepsis,  and  thus  we  call  anything  that  tends  to  prevent  or 
stop  sepsis  or  infection  antiseptic.  We  may  use  it  of  the  system 
we  employ  to  prevent  the  state  of  sepsis  or  infection  from  com- 
ing about,  and  thus  speak  of  antiseptic  precautions  and  anti- 
septic surgery;  or  we  may  apply  it  to  the  thing  that  actually 
stops  already  existing  infection  or  sepsis,  and  accordingly  call 
such  things  as  weak  solutions  of  bichloride,  Dakin's  solution, 
etc.,  antiseptics.  There  are  many  other  agents  which  will  do 
this,  such  as  heat,  strong  solutions  of  bichloride,  etc.,  but  the 
term  antiseptic  is  usually  applied  to  only  those  which  can  be 
used  upon  the  living  body. 

Disinfectant. —  As  the  term  implies,  the  prefix,  dis-,  meaning 
to  deprive  of,  a  disinfectant  is  something  which  removes  in- 
fection. In  its  strictest  technical  meaning  disinfectant  is  prop- 
erly used  to  signify  only  those  agents  which  destroy  disease- 
producing  bacteria,  and  only  such  of  those  as  cannot  be  used 
upon  the  living  body;  but  in  everyday  practice  it  is  impossible 
to  draw  any  line  of  demarcation  between  our  bacteria  and  so, 
in  everyday  speech,  we  apply  the  term  more  broadly  and  in- 
clude almost  every  form  of  bacteria-removing  agent,  and  even 
go  so  far  as  to  call  soap  and  water  a  disinfectant  because,  by 
using  them  together,  we  can,  though  under  heavy  limitations, 
remove  infection.  Thus,  we  take  disinfectant  out  of  the  class 
of  destroyers  and  make  it  merely  a  remover,  which  is  perhaps 
not  justice  to  the  spirit  of  the  word,  and  certainly  is  not  con- 
sistent with  our  other  usages  of  the  term  when,  for  instance,  we 
call  heat,  formaldehyde  gas,  etc.,  disinfectants.  However,  the 
name  is  unimportant  so  long  as  we  know  the  truth. 

Bactericide. — Here,  again,  our  term  defines  itself.  The 
suffix  -cide  means  destroyer,  and  so  a  bactericide  is  simply  some- 
thing which  can  kill  bacteria. 

Germicide. — As  the  term  implies,  a  germicide  is  an  agent 


234  TEXTBOOK  OF  SURGICAL  NURSING 

which  can  destroy  germs,  or  bacteria.  In  the  surgical  sense 
the  terms  bacteria  and  germs  are  used  interchangeably,  so  it 
does  not  materially  matter  which  we  use  here. 

Sterilization. — This  is  really  our  major  term,  for  it  is  larger 
than  all  the  rest  in  that  it  signifies  the  absolute  destruction  of 
all  forms  of  bacteria. 

Technic. — This  is  a  word  which  we  use  a  great  deal  and 
which  often  seems  to  be  regarded  as  the  name  of  something  very 
formidable.  It  is  the  name  of  something  Aan*y  important  as  it 
is  applied  in  the  operating  room,  but  as  is  so  often  the  case, 
this  very  important  thing  is,  in  actuality,  a  very  simple  one, 
Technic  is  nothing  more  nor  less  than  the  way  of  doing  a  thing, 
and  in  the  operating  room  it  is  merely  the  way  in  which  we 
make  and  keep  things  sterile.  Even  in  this  sense,  however, 
there  is  a  danger  of  its  becoming  something  of  a  bugbear  and 
of  its  developing  into  a  hindrance  rather  than  the  help  it  is 
designed  to  be  and  always  should  be.  Simplicity  is  the  key- 
note of  good  technic,  as  it  is  the  kejaiote  of  all  good  human 
endeavor,  and  the  less  complex  we  make  it  the  fewer  will  be  our 
points  of  contact  with  those  things  which  have  the  power  to 
make  it  fail. 

In  the  operating  room,  then,  we  have  all  the  terms  we  have 
just  defined  as  startling  watchwords,  but  the  greatest  of  them 
are  septic,  or  infected,  and  sterilization;  for  we  must  treat 
everything  that  is  to  come  into  contact  with  a  wound,  either  di- 
rectly or  the  most  remotely  indirectly,  as  though  it  were  septic 
or  infected  and  must  sterilize  it  before  it  is  used ;  and,  of  course, 
it  goes  without  saying  that  we  must  keep  it  so.  Words  and 
their  definitions  are  important,  but  they  will  not  keep  a  wound 
free  from  infection  unless  they  are  put  into  practice  with  an 
intelligence  and  a  conscience,  and  with  a  skill  that  can  be  ac- 
quired only  by  diligent  application. 

Much  will  have  been  learned  in  the  classroom  and  on  the 
wards  about  sterilization,  antisepsis,  asepsis,  and  all  the  rest, 
and  the  nurse  will  know  in  a  general  way  how  to  sterilize  many 
things  and  how  to  keep  them  sterile ;  but  in  the  operating  room 
she  will  find  a  rigidity  and  a  minuteness  of  technic  which  at 
first  will  seem  to  have  no  relation  to  what  she  has  previously 


OPERATING  ROOM  STERILIZATION  235 

practiced.  On  the  wards  she  had  to  deal  only  with  wounds 
which  were  partially  healed  and  which  were  not,  therefore,  so 
susceptible  to  infection  as  fresh  ones,  and  for  this  reason  she 
was  permitted  many  practices  which  would  be  very  dangerous 
in  the  operating  room  where  the  wound  is  fresh  and  in  its  most 
infectible  state.  Also,  in  the  wards  the  supplies  which  she 
handled  were  used  only  on  the  surface  of  a  wound  or  within 
an  infected  one  which  is  very  largely  protected  from  new  in- 
fection by  its  own  excretions,  while  in  the  operating  room  she 
deals  with  the  things  that  are  to  come  into  closest  contact  with 
the  entire  area  of  a  freshly  made  wound  and  even  with  the 
blood  stream  itself.  Her  problem,  therefore,  is  a  much  more 
serious  one,  and  her  methods  must  be  in  accordance. 

THE  AGENTS 

The  subject  of  practical  sterilization  is  a  rather  troublesome 
one  to  master  because  of  the  fact  that  the  various  articles 
needed  in  surgery  differ  so  widely  in  composition  and  there- 
fore in  the  amount  and  means  of  sterilization  to  which  they 
may  be  subjected  without  injury.  By  long  experience  and 
practice,  however,  during  the  period  of  time  since  Lister  gave 
the  world  the  discovery  of  aseptic  surgery  (see  "Introduction 
and  History"),  one  or  more  good  methods  have  been  evolved  for 
the  sterilization  of  every  substance  with  which  we  have  to  deal, 
and  so  our  present  task  is  simplj^  to  learn,  article  by  article,  the 
special  recognized  method  which  is  adapted  to  each  individual 
case.  The  numerous  and  somewhat  tedious  methods  may  be 
clarified  to  some  degree  for  the  student  if  she  will  learn,  and 
then  remember,  as  she  plods  through  the  details  of  the  follow- 
ing pages,  that,  after  all,  each  one  may  he  classified  under  one 
of  two  great  classes,  and  that  whatever  particular  process  she 
is  carrying  out  is  simply  an  adaptation  of  one  of  these  two 
major  methods,  and  that  the  special  variation  is  dictated  by 
some  material  peculiarity  for  which  nature  is  responsible. 

These  two  major  classes  of  sterilizing  agencies  are :  Thermal 
and  Chemical. 

You  will  be  taught  one  or  two  other  classes  by  many  authori- 


236  TEXTBOOK  OF  SURGICAL  NURSING 

ties.  For  instaiu'e,  you  ^vill  be  given  the  class  "mechanical," 
and  the  example  for  it  will  be  the  cleansing  of  the  hands,  etc., 
with  soap,  water,  and  brush;  but  it  is  a  fact  that,  in  the  last 
analysis  it  is  the  soap  and  water  w'hieh  constitute  the  steriliz- 
ing agency  in  the  case,  and  as  they  are  chemicals  "scrubbing" 
may  very  consistently  be  called  a  chemical  sterilizing  agent, 
with  the  brush  throAvn  in.  In  fact,  if  the  brush  is  given  too 
much  prominence  in  the  process  it  can  do  more  harm  than  good 
by  scratching  the  skin  and  making  harbors  for  infection.  You 
will  also  see  the  term  "light"  used  for  another  class,  and  in 
your  experience  you  may  have  seen  wounds  treated  by  exposure 
to  the  sunlight,  and  you  know  that  sun  does  kill  some  germs 
easily,  but  this  may  be  regarded  as  another  ease  of  chemical 
action  for  there  is  considerable  evidence  for  the  belief  that 
it  is  the  "actinic"  or  chemical  element  in  the  raj's  of  the  sun 
that  does  this  Avork. 

All  of  the  sterilizing  agents  in  common  use,  then,  may  be 
classified  under  the  two  main  heads  which,  for  a  little  more  sim- 
plicity, maj''  be  subdivided  as  follows: 

I.     THERMAL 

1.  Moist  Heat 

a.  Boiling  water 
h.  Steam 

2.  Dry  Heat 

a.  Hot  air 

b.  Flame 

c.  Actual  cautery 

II.     CHEMICAL — All  sohitions  of  chemicals  which  have  the 
power  to  kill  germs. 

I.     THERMAL    STERILIZATION 

Of  the  two  forms  of  thermal  sterilization,  the  moist  and  the 
dry,  the  moist  form  is  the  more  effective  at  a  given  temperature 
and  period  of  exposure,  experiment  showing  that  the  very 
hardy  anthrax  spores,  for  example,  are  killed  by  boiling  water 
(212°  F.)  in  about  12  minutes,  whereas  dry  air  at  a  tempera- 
ture of  300°  F.  requires  almost  3  hours.  The  moist  form  is, 
therefore,  more  practical  and  it  is  fortunate  that  by  far  the 


OPERATING  ROOM  STERITJZATiON  237 

greater  proportion  of  surgical  supplies  may  be  subjected  to  it. 
The  reason  why  the  moist  form  is  the  more  active  is  a  complex 
one  which  it  must  be  left  to  the  several  sciences  involved  to 
explain.  We  have  only  time  and  space  here  to  point  out  the 
practical  poM'ers  of  each  which  we  make  use  of  in  our  art  and 
to  prescribe  the  particular  one  best  suited  to  the  sterilization  of 
each  of  the  numerous  materials  and  articles  which  we  employ 
in  aseptic  surgery. 

1.  Moist  Heat. — a.  Boiling  Water. — This  is  the  simplest 
agent  to  use  and  if  it  did  not  destroy,  or  render  unfit  for  use,  so 
many  articles,  it  would  make  our  problem  of  sterilization  a  very 
easy  one  to  solve,  for  boiling  water  kills  most  known  forms  of 
disease-producing  germs  and  their  spores  in  a  few  minutes. 
Plain  water,  as  you  know,  boils  at  212°  Fahrenheit;  and  as  we 
shall  point  out  later,  in  some  cases  we  use  enough  carbonate  of 
soda  (washing  soda)  in  it  to  make  a  1%  solution,  which  raises 
the  boiling  point  4°  Fahrenheit  and  at  the  same  time  supplies 
an  additional  solvent  power  to  the  water  which  is  very  service- 
able in  that  it  makes  more  certain  the  actual  cleanliness  of  the 
articles  which  have  passed  through  it.  In  addition  to  this,  the 
washing  soda  counteracts  the  oxidizing  or  "rusting"  power  of 
plain  water,  and  this  makes  it  especially  valuable  for  our  metal 
supplies. 

h.  Steam. — Next  to  boiling  water,  steam  is  our  best  friend, 
though  the  application  of  it  necessitates  special  and  more  or 
less  complex  equipment.  Steam  is  simply  water  which  has 
been  converted  into  another  form,  vapor,  by  boiling ;  in  its  nor- 
mal state,  therefore,  it  is  no  hotter  than  boiling  water,  and  of 
no  more  value  as  a  sterilizing  agent.  It  is  a  physical  fact, 
however,  that  if  we  compress  this  steam  we  increase  its  tempera- 
ture and  its  efficiency  otherwise,  and  the  more  we  compress  it 
the  higher  its  temperature  becomes;  and  so  it  has  come  about 
that  numerous  instruments,  "steam  pressure  sterilizers"  (Fig. 
49),  have  been  invented  in  which  we  can  sterilize  certain  sur- 
gical supplies,  which  are  not  suitable  to  boiling,  in  this  com- 
pressed steam. 

At  this  point  w^e  shall  stop  to  study  the  general  mechanism 


238 


TEXTBOOK  OF  SURGICAL  NURSING 


of  the  "steam  pressure  sterilizer"  so  that  we  shall  be  able  to 
understand  more  clearly  the  explanation  further  on  as  to  why 
we  use  it.  ■ 

There  are  many  designs  of  steam  sterilizers  on  the  market 
and  no  tAvo  of  them  are  exactly  alike  in  detail  of  structure,  but 
they  are  alike  in  essential  prinriplcs  ami  If  we  have  a  clear 
idea  of  these  general  principles  we  shall  have  no  serious  diffi- 
culty in  learning  to  operate  any  particular  type  that  we  may 


Fig.   49. 


-Steam   I'rf.sscre  Dressing   Sterilizer.     The   construction   and 
operation  ot  this  sterilizer  are  explained  on  page  239. 


encounter  in  practice.  It  is  a  fact  that  the  average  nurse  is 
greatl}^  puzzled  by  these  sterilizers  when  she  first  undertakes 
to  operate  them,  she  is  afraid  of  them,  and  w^hen  she  does  finally 
learn  to  control  them  she  performs  the  duty  in  a  rather  per- 
functory way  and  takes  little  interest  in  her  instrument  beyond 
knowing  the  serial  order  in  which  the  valves  are  turned  on  and 
off.  Perhaps  this  common  attitude  among  pupil  nurses  is  due 
to  the  fact  that  they  are  women  and  therefore  not  interested  in 
things  jnechanical,  but  whether  or  not  that  is  the  reason,  the 
attitude  is  a  bad  one  and  an  unnecessary  one  because  a  few 


OPERATING  ROOM  STERILIZATION  239 

moments  of  study  will  make  any  one  of  these  sterilizers  very 
intelligible  and  even  simple  to  any  pupil  and  ^vill  prevent  its 
becoming  the  bugaboo  it  too  often  does. 

In  a  few  words,  using  Figure  49  as  our  guide,  the  secrets  of 
this  instrument  are  these:  The  large  cylindrical  part  is  a 
strong,  hollow,  steel  shell  which  contains  water,  and  is  caUed 
the  "jacket";  underneath  this  is  the  gas  burner,  steam  pipe 
or  other  heater  which  boils  the  water  and  converts  it  into 
steam.  This  "jacket"  is,  of  course,  steam-tight,  and  as  the 
steam  increases  in  quantity  it  necessarily  becomes  more  and 
more  compressed  and  correspondingly  hotter.  The  two  clock- 
like dials  on  the  top  of  the  cylinder  in  front  are  '^  steam 
gauges,"  which  indicate  in  pounds  the  pressure  of  the  steam; 
one  of  these  is  connected  with  the  "jacket''  and  the  other  we 
shall  speak  of  presently.  On  the  top  of  the  cylinder  at  the 
rear  are  several  valves;  one  of  these  connects  the  "jacket"  with 
the  interior  of  the  sterilizer,  the  '^ chamher,"  into  which  we 
put  our  supplies  for  sterilization.  The  door  to  the  "chamber" 
is  fitted  with  heavy  bolts  which  enable  us  to  fasten  it  so  as  to 
make  the  "chamber"  as  steam-tight  as  the  "jacket."  "When 
we  have  the  desired  amount  of  steam  pressure  in  the  "jacket" 
we  then  open  the  valve  we  have  just  mentioned  and  allow  the 
steam  to  enter  the  "chamber"  where  it  permeates  our  supplies. 
The  water  is  still  boiling  and  giving  off  steam  to  fill  this  new 
space  and  in  a  few  moments  we  have  the  same  pressure  in  the 
"chamber"  as  in  the  "jacket,"  as  we  can  tell  by  the  second 
"steam  gauge,"  which  is  connected  with  the  "chamber."  The 
"jacket"  and  "chamber"  are  now  in  direct  communication 
through  the  steam  valve  and  we  leave  them  so  till  we  have  fin- 
ished our  sterilization.  The  standard  amount  of  steam  pressure 
which  is  used  in  these  sterilizers  is  15  pounds,  and  at  this  pres- 
sure the  temperature  of  the  steam  is  about  250^  Fahrenheit, 
or  38°  F.  higher  than  boiling  water.  The  sterilizer  is  fitted 
with  a  "safety  valve"  which  is  regulated  so  as  to  open  auto- 
matically when  more  than  this  amount  of  steam  accumulates 
and  allow  it  to  escape.     The  details  as  to  time  of  sterilization. 


240  TEXTBOOK  OF  SURGICAL  NURSING 

etc.,  will  be  given  ^vllen  T^-e  describe,  later  on,  the  sterilization 
of  individual  articles. 

This  is  the  A,  B,  C  of  sterilization  by  means  of  the  steam 
pressure  sterilizer,  but  when  you  come  to  actually  operate  one 
of  the  more  complex  sterilizers  you  will  find  a  few  more  valves 
and  other  attachments ;  these,  however,  will  be  clearly  explained 
by  the  manufacturer  who  always  supplies  printed  instructions, 
and  it  is  important  that  the  nurse  should  have  before  her  these 
instructions  at  all  times  until  she  thoroughly  masters  the 
mechanism  of  any  sterilizer  she  may  need  to  operate,  for  the 
various  designs  differ  in  essential  details. 

A  very  important  feature  which  will  be  encountered  in  all 
the  better  ones  is  an  arrangement  for  creatwg  a  "vacuum"; 
and  this  brings  us  to  a  subject  which  we  have  not  yet  mentioned, 
namely,  sterilization  by  steam  pressure  in  a  vacuum.  Those 
of  you  who  have  studied  physics  will  know  that  a  vacuum  is  a 
space  which  has  nothing  in  it,  not  even  air,  and  when  we  use 
the  term  in  connection  with  the  sterilizer  we  simply  mean  the 
"chamber"  which  has  had  the  air  sucked  from  it;  and  the 
"vacuum  valve"  which  you  will  find  on  your  sterilizer  means 
simply  a  valve  which  is  so  made  that  it  may  be  turned  to  allow 
the  steam  in  the  "jacket"  to  suck  all  the  air  out  of  the  "cham- 
ber." This  creation  of  the  vacuum  is,  of  course,  done  before 
the  steam  is  allowed  to  enter  the  "chamber,"  and  so  we  are 
then  able  to  sterilize  in  a  vacuum. 

The  nurse  will  now  reasonably  ask  two  questions :  * '  Why  do 
we  sterilize  in  a  vacuum?"  and  more  insistently,  "Why,  if  boil- 
ing water  is  hot  enough  to  sterilize,  do  ive  need  to  heat  steam — 
practically  the  same  thing — to  a  so  much  higher  degree?"  The 
answer  to  the  first  question  is  simply  that,  since  by  a  law  of 
physics  no  two  substances  can  occupy  atomically  the  same  place 
at  the  same  time,  therefore,  speaking  atomically,  where  there  is 
air  there  can  be  no  steam,  and  as  air  serves  no  useful  purpose 
we  remove  it  so  that  the  useful  steam  may  have  its  place.  The 
answer  to  the  second  question  is  that  we  do  not  compress  the 
steam  so  much  to  raise  its  temperature  as  we  do  to  make  it 
penetrate  to  the  interior  of  the  more  or  less  compact  parcels 


OPERATING  ROOM  STERILIZATION  241 

of  fabric  which  constitute  almost  entirely  the  supplies  which 
we  sterilize  by  this  means. 

Finally,  these  sterilizers  provide  for  the  absolute  drying  of 
our  supplies  after  they  are  sterile,  and  they  accomplish  this  by 
sucking  out  the  moisture  just  as  the  air  was  previously  sucked 
out.  And  here,  we  may  now  point  out,  is  the  answer  to  an- 
other question  which  might  arise,  namely,  "Why  not  simply 
boil  these  supplies,  since  they  must  become  as  wet  in  the  sterilizer 
as  they  would  in  a  boiler,  and  since  they  certainly  become  much 
hotter?"  Both  of  these  things  do  happen  to  them,  but  what 
cannot  happen  to  them  in  the  boiler  is  the  thorough  drying 
which  is  an  absolute  necessity  for  those  things  which  we  ster- 
ilize in  this  way.  Another  point  here  is  that  steam  is  free  from 
all  the  numerous  impurities  such  as  lime,  iron,  etc.,  which  are 
usually  found  in  water;  and  so,  in  the  steam  our  supplies  es- 
cape a  considerable  amount  of  soiling  and  staining  from  which 
they  would  suff^er  greatly  in  boiling. 

From  time  to  time  these  sterilizers  must  he  tested  because 
there  are  many  ways  in  which  they  may  become  disordered  and 
so  fail  to  sterilize.  There  are  a  number  of  chemical  and  other 
inventions  on  the  market  which  are  designed  to  serve  this  pur- 
pose and  some  of  them  are  doubtless  reliable,  but  the  safest 
test  is  an  actual  culture  of  some  known  resistant  bacteria, 
placed  in  the  center  of  the  largest  and  most  tightly  packed  par- 
cel and  subjected  to  the  customary  sterilization  process.  The 
pathological  laboratory  will  have  to  be  depended  upon  for  the 
culture  and  for  the  bacteriological  examination  afterward. 

2.  Dry  Heat.— a.  Hot  Air.— To  sterilize  by  means  of  dry 
air  a  very  high  temperature  is  necessary  and  it  must  be  applied 
for  a  long  time,  a  temperature  of  300°F.  for  one  hour  perhaps 
being  no  more  than  the  equivalent  of  boiling  water  (212°F.) 
for  15  minutes.  Relatively  few  materials  will  survive  this  de- 
gree of  heat  without  being  injured  to  some  extent,  but  there 
may  be  occasions  when  no  other  means  will  be  at  hand,  so  we 
must  know  how  to  make  use  of  it.  A  hot  air  sterilizer  (Fig. 
50),  in  principle,  is  merely  an  ordinary  baking  oven,  and  when 
nothing  better  is  available  the  kitchen  oven  may  be  pressed  into 


242 


TEXTBOOK  OF  SURGICAL  NURSING 


service.     A   thermometer  is  always   an   important  attachment 
for  this  sterilizer,  of  course. 

h.  Flame. — Some  articles  may  be  sterilized  by  passing  them 
through  the  flame  of  an  alcohol  lamp  or  a  gas  burner.  Also,  an 
emergency  means  of  sterilizing  the  inside  of  metal  or  other  fire- 
proof basins  or  dishes  is  to  pour  a  very  small  amount  of  alcohol 
(methyl  alcohol  is  best)  into  them,  light  it  with  a  match,  and 
allow  it  to  burn  out.  This  is  a  rather  dangerous  method,  and 
wlien  it  is  practiced  great  care  must  be  taken  to  use  only  enough 


Pig.  50. — Hot  Air  Sterilizer. 


alcohol  to  barely  wet  the  surface  of  the  article,  for  it  burns 
slowly  and  with  a  high  degree  of  heat ;  pains  must  be  taken  not 
to  spill  the  alcohol  anywhere  in  the  neighborhood ;  and  the  bot- 
tle must  be  removed  to  a  safe  distance  before  the  match  is 
lighted. 

c.  Actual  Cautery. — The  nurse  will  probably  never  be  called 
upon  actuallj^  to  use  this  instrument  herself,  as  its  chief  appli- 
cations are  for  the  sterilization  of  the  appendix  stump  after  the 
appendix  has  been  removed,  for  the  removal  of  hemorrhoids,  or 
for  the  cauterization  of  tumors,  ulcers,  etc.  Its  care  and  prepara- 
tion for  use,  however,  will  be  her  duty  and  she  should  become 
familiar  with  it. 


OPERATING  ROOM  STERILIZATION 


243 


The  actual  cautery  may  be  of  one  of  these  three  varieties: 
(a)  A  simple  iron  (Fig.  51)  similar  to  the  soldering  iron  used 
by  a  plumber,  and  modifications  of  this  for  special  uses.     These 


Fig.  51. — The  Mayo  Soldering  Iron  Cautery  with  Special  Gas  Burner 
FOR  Heating  It.     The  irons  are  made  in  several  shapes  and  sizes. 

may  be  heated  in  any  flame,  but  a  special  burner  shown  in  the 
illustration  accompanies  the  particular  type  called  the  Mayo 
cautery.  .  The  only  attention  these  irons  will  need  to  keep  them 


Fig.  52. — Electric  Cautery. 


in  good  condition  is  to  scour  them  after  use  with  a  hard  scouring 
powder  (emery,  for  example)  or  with  a  piece  of  fine  sandpaper. 
(&)   The  electric  cautery   (Fig.  52),  for  which  also  there  are 


244  TEXTBOOK  OF  SURGICAL  NURSING 

points  of  a  variety  of  sizes  and  designs,  (c)  The  FaqucUn 
cautery  (Fig.  53),  or  one  constructed  on  its  general  princijiles. 
This  is  a- complex  instrument  Avhich  requires  careful  JuDidJiiig 
to  keep  it  in  working  order;  and  as  it  will  usually  be  the  nurse's 
duty  to  hand  it  to  the  surgeon  ready  for  applieation  every  nurse 
should  make  sure  that  slie  inulcivstaiuls  it  and  that  she  ean  prop- 
erly heat  it.  This  cautery  consists  of  a  hollow  platinum  point 
which  is  kept  hot  by  the  burning  of  benzine  vapor  pumped 
through  it  from  a  small  reservoir  by  means  of  a  rubber  bulb. 
In  practice  this  cautery  is  often  very  unsatisfactory^  because  it 
fails  to  become  or  remain  hot ;  but  if  the  hollow  i)latiiuim  point 
is  not  punctured,  and  if  its  cavity  is  not  obstructed  by  a  dent, 
its  failure  is  nearly  always  due  to  the  fact  that  the  person 


Fig.  53.— The  Paquelin  Cautery. 

manipulating  it  does  not  quite  understand  how  it  must  be 
treated.  In  the  first  place,  the  platinum  points  are  very  soft 
and  therefore  easily  bent  or  dented,  and  tliey  must  always  be 
handled  gently  and  protected  from  accident.  But  gi^'en  a  point 
in  good  condition,  practically  all  failures  with  this  cautery  are 
due  to  the  fact  that  the  proper  procedure  has  not  been  followed 
in  heating  it.  The  benzine  reservoir  contains  a  sponge,  and  in 
filling  it  only  enough  benzine  sliould  be  put  into  it  to  saturate 
the  sponge,  for  it  is  only  the  vapor  that  will  serve  our  purpose, 
and  if  there  is  more  benzine  than  the  sponge  will  absorb  the 
fluid  itself  will  be  pumped  into  the  point  and  clog  it.  A  good 
practice  is  to  invert  the  tank  after  filling  it  to  allow  the  excess 
to  escape.  The  next,  and  perhaps  the  most  important  precau- 
tion to  be  taken  is  that  the  platinum  point  must  be  heated  red 
hot    (in  a  gas  or  alcoliol  flame)    before  the  benzine  vapor  is 


OPERATING  ROOM  STERILIZATION  245 

pumped  into  it.  The  reason  for  this  will  be  evident  when  it  is 
understood  that  it  is  the  combustion  of  the  benzine  vapor  within 
the  point  that  keeps  it  hot,  and  if  the  point  is  not  hot  enough  to 
burn  this  vapor  there  will  simply  be  an  accumulation  of  con- 
densed vapor  Avithin  the  point  which  will  nearly  always  obstruct 
it.  The  warning^  then,  is  to  wait  until  the  point  is  red-hot  and 
then  begin  pumping  the  vapor  into  it  slowly  and  steadily  and 
to  continue  thus  with  the  point  in  the  flame  for  a  few  moments 
until  the  circulation  of  the  benzine  vapor  is  well  established. 
The  point  can  then  be  removed  from  the  flame  and  kept  red  hot 
by  the  steady  pumping  of  the  benzine  vapor.  An  important 
thing  to  remember  is  that  too  much  must  not  be  expected  of  this 
small  red-hot  piece  of  metal,  and  when  large  amounts  of  tissue 
are  to  be  burned  with  it  the  larger  points  should  be  used;  for 
naturally,  the  burning  is  accomplished  by  the  transference  of 
the  heat  from  the  platinum  point  to  the  tissue,  and  if  too  much 
tissue  surrounds  it  at  any  given  time  it  is  overcome  by  having  its 
heat  used  up  faster  than  it  is  able  to  produce  it.  Thus  it  often 
happens  that  the  "fire"  in  the  point  goes  out  during  a  heavy 
cauterizing  operation,  and  as  soon  as  this  happens  the  pumping 
must  be  stopped  and  the  point  reheated  in  a  flame  as  in  the 
beginning.  If  the  Paquelin  point  is  always  treated  with  the  care 
outlined  here  it  will  always  respond. 

II.     CHEMICAL    STERILIZATION 

Chemical  sterilization  is  simj^ly  the  soaking  of  articles  in  a 
solution  of  a  chemical,  which  has  the  power  to  kill  germs,  for  the 
length  of  time  which  experiment  has  proved  each  individual 
chemical  requires.  It  would  be  almost  impossible  to  enumerate 
the  various  chemicals  which  have  been  advocated  from  time  to 
time  for  this  purpose,  for  as  very  few  of  them  are  entirely  satis- 
factory new  ones  are  always  coming  into  favor  in  the  hope  that 
the  various  objections  to  the  old  ones  may  be  avoided.  There  are 
a  few,  however,  which  have  stood  the  test  of  time  and  experience, 
and  though  individual  authorities  will  always  vary  in  their 
preferences  of  even  these  "tried  and  true"  ones,  we  are  safe  in 
saying  that  the  following  are  the  important  chemical  sterilizing 
agents,  and  that  they  are  mentioned  in  the  order  of  their  latitude 


246  TEXTBOOK  OF  SURGICAL  NURSING 

of  general  application  in  modern  surgery:  Bichloride  of  mer- 
cury, iodine,  alcohol,  carbolic  acid,  Dakin's  solution,  formalin, 
lysol,  ether. 

PRACTICAL  METHODS 

(For  Initial  Preparation  of  Supplies  see  Chapter  XIV) 

One  of  the  first  principles  to  be  learned  by  the  operating  room 
beginner  is  to  reduce  the  handling  of  sterile  supplies  to  the  very 
lowest  point.  Tlie  methods  we  shall  give  you  in  the  following 
pages  we  believe  to  be  perfectly  safe  and  if  you  follow  them 
conscientiously  we  believe  your  supplies  will  be  sterile,  but  we 
must  always  remember  that  the  human  element  in  all  our  acts 
perpetuates  the  possibility  of  mistakes  and,  therefore,  every  time 
one  avoids  handling  a  sterile  thing  one  escapes  a  possibility  of 
contaminating  it.  This  applies  particularly  after  the  thing  is 
sterile,  of  course,  but  one  must  begin  the  application  of  the  prin- 
ciples with  the  packing  of  the  supplies  for  sterilization  because 
the  way  in  w^hich  this  is  done  will  determine  to  no  small  degree 
the  amount  of  necessary  subsequent  handling.  The  element  of 
time  saA'ing  also  enters  here,  for,  on  the  whole,  the  more  quickly, 
or,  rather,  the  more  directly  a  sterile  thing  reaches  the  Avound 
from  the  sterilizer  the  more  certain  one  can  be  of  its  asepsis; 
and  so,  while  we  are  aiming  to  avoid  frequency  of  handling  we 
must  also  aim  to  reduce  as  much  as  possible  the  duration  of  each 
particular  act  of  handling.  We  shall  try,  then,  to  pack  our 
supplies  in  the  most  convenient  and  accessible  form  possible; 
and  as  we  take  up  each  type  of  supplies  we  shall  carry  it  through 
its  particular  process  of  sterilization. 

There  are  certain  supplies,  such  as  basins,  irrigators,  etc., 
which  wdll  be  awkward  to  store  sterilly;  and  there  are  others, 
the  instruments  for  example,  for  which  there  is  no  suitable 
method  by  Avhich  they  may  be  thus  stored  and  at  the  same  time 
kept  in  good  condition.  In  such  cases  sterilization,  by  boiling 
chiefly,  immediately  before  use  will  have  to  be  the  practice. 

Gauze  and  Muslin  Supplies. — We  shall  presume  first  that 
you  are  equipped  with  the  drums  for  these  supplies  and  that 
you  are  packing  for  a  session  of  two  or  more  operations.  In 
this  case  you  will  do  best  to  use  a  set  of  four  drums,  and  to 


OPERATING  ROOM  STERILIZATION  247 

devote  one  entirely  to  each  of  the  following  groups:  (1)  Gauze 
sponges,  all  wound  dressings,  and  a  few  towels;  (2)  Draping 
sheets  and  towels;  (3)  Gowns,  or  aprons  and  gauntlets;  (4) 
Abdominal  pads  and  towels  (the  hot  towel  drum).  Such  things 
as  packing,  the  lithotomy  towel  and  stockings,  sterile  bandages, 
cotton,  etc.,  which  are  only  occasionally  used,  are  best  packed 
in  individual  muslin-covered  parcels.  Or,  for  the  packing,  a 
convenient  plan  is  to  pack  it  in  long  glass  tubes  which  are  well 
plugged  with  cotton  and  wrapped  in  a  muslin  cover.  One  doc- 
tor's suit  or  gown,  a  cap,  and  a  mask  are  best  packed  together 
in  a  parcel  for  each  individual  according  to  size ;  likewise,  there 
should  be  a  similar  set  of  cap,  gown,  and  mask  for  each  nurse, 
as  these  articles  will  be  needed  in  the  dressing  room,  and  but 
once  for  a  session.  When  the  gauntlets  are  used  a  supply  of 
rubber  bands  or  safety  pins  for  holding  them  in  place  should 
be  packed  with  them. 

If  drums  are  not  used  about  the  only  substitute  will  be  the 
muslin-covered  parcels,  and  when  preparation  is  made  for  sev- 
eral operations  to  be  done  at  one  time  the  general  plan  given 
above  for  the  drums  will  work  well.  However,  with  the  muslin- 
covered  parcels  there  will  always  be  more  handling  required  in 
opening  and  disposing  the  contents  upon  tables,  and  for  this 
reason  it  may  be  better  to  combine  them  into  fewer  individual 
parcels.  How  this  is  done  must  be  left  to  the  ingenuity  of  the 
nurse  who  will  be  guided  by  her  equipment  and  the  nature  of  her 
work;  but  she  must  always  keep  in  mind  her  goal  of  simplicity 
and  minimum  amount  of  handling  and  exposure. 

In  small  operating  rooms,  where  only  one  operation  need  be 
prepared  for,  one  drum  or  one  parcel  may  be  used  for  all  these 
supplies  except,  of  course,  the  individual  wearing  apparel, 
which  should  be  arranged  as  in  the  other  cases. 

All  of  these  supplies  are  sterilized  in  the  steam  pressure 
sterilizer,  and  they  should  be  exposed  to  the  steam  at  15  pounds 
pressure  (250°  F.)  for  45  minutes,  and  to  the  drying  process 
for  from  20  to  30  minutes  or  more,  according  to  the  load. 

Rubber  Gloves. — The  gloves  should,  first  of  all,  be  most 
carefidly  tested  to  eliminate  those  wath  the  slightest  perforation 
(see  page  294).     They  are  then  poivdered  well  and  evenly  on 


248  TEXTBOOK  OF  SURGICAL  NURSING 

both  sides  with  talcum  powder;  the  culj  hinicd  up  over  the  out- 
side for  about  2  inches;  and  phieed  in  the  muslin  covers,  if  these 
have  been  provided,  and  otherwise  folded  in  a  tv)wrl.  If  the 
towel  is  used  it  should  be  so  folded  about  the  gloves  that  a  layer 
of  it  comes  between  them  for  this  will  aid  in  permitting  the 
steam  to  reach  all  parts.  It  is  best  teehnie  to  provide  a  separate 
glove  cover  or  towel  for  each  pair  of  gloves ;  and  with  each  pair 
should  be  included  a  small  packet  of  talcum  poivder,  as  the 
hands  wdll  always  need  to  be  well  powdered  before  attempting 
to  put  on  the  gloves.  This  powder  is  best  wrapped  loosely  in  a 
piece  of  thin  paper. 

These  parcels  of  one  pair  each  are  then  packed  together  in  a 
drum  or  muslin  cover,  enough  pairs  being  provided  for  accidents 
such  as  tearing  or  unsterilizing.  A  few  towels  should  be 
included  in  this  parcel  for  use  in  drying  the  hands. 

It  is  a  good  practice,  before  sterilizing  new  gloves  for  the 
first  time,  to  scrub  them  well  and  hoil  them  for  a  few  minutes, 
as  some  brands  will  come  out  of  the  first  sterilization  covered 
with  a  more  or  less  gummy  substance.  The  scrubbing  and  boil- 
ing will  prevent  this,  and  in  any  case  it  is  advisable  to  be  sure 
that  anything  one  sterilizes  has  had  the  cleanest  start  possible. 

Gloves  are  sterilized  in  the  steam  sterilizer  at  15  pounds  pres- 
sure, and  they  can  never  be  subjected  to  the  steam  for  more  than 
20  minutes  without  greatly  injuring  them.  If  they  are  not 
packed  too  tightly  10  minutes  will  be  enough.  Drying  should 
be  accomplished  inside  of  20  minutes  also,  and  if  loosely  packed 
10  or  15  minutes  Avill  suffice.  Rubber  does  not  withstand  high 
temperatures  well,  and  if  damaged  in  sterilization  gloves  are 
easily  torn  and  may  then  be  as  much  of  a  menace  as  when 
imperfectly  sterilized ;  for  it  must  be  remembered  that  the  hands 
are  never  considered  absolutely  sterile.  This  is  the  "dry 
method"  of  glove  sterilization. 

Some  surgeons  will  prefer  '^wet-sterilized"  gloves,  and  in 
that  case  the  gloves  are  boiled  for  10  minutes  and  then  stored 
in  a  basin  of  some  antiseptic  solution  from  which  they  are  used 
directly.  The  particular  solution  used  will  be  a  matter  of  indi- 
vidual preference  but  will  probably  be  either  a  1-1000  solution 
of  bichloride  of  mercury,  1-60  carbolic  acid,  or  lysol  %%  or  1%. 


OPERATING  ROOM  STERILIZATION  249 

The  advantage  of  gloves  used  in  this  way  is  that  the  hands 
remain  wet  with  the  solution  and  are  doubtless  more  nearly 
sterile  than  they  are  with  the  dry  gloves,  and  an  accidental 
puncture  is  more  likely  to  be  harmless ;  but  the  dry  ones  are  more 
extensively  preferred  because  they  are  more  comfortable  and 
they  avoid  the  complication  of  sore  hands  which  sometimes  is  an 
annoying  accompaniment  of  the  practice  of  using  wet  gloves. 

As  in  the  case  of  all  boiling  of  rubber,  the  gloves  must  not 
he  put  into  the  water  until  it  has  reached  the  boiling  point 
because  they  deteriorate  somewhat  at  best  in  the  hot  water  •  also, 
only  plain  water  must  be  used,  as  for  all  rubber,  and  never  the 
soda  solution  for  the  two  reasons  that  it  is  not  necessary  and 
that  it  is  very  detrimental  to  rubber. 

A  hint  which  it  may  be  well  for  the  nurse  to  pick  up  here  is 
that  old  rubber  which  has  lost  its  "life"  may  be  somewhat 
rejuvenated  by  boiling  it  for  a  few  moments  in  a  weak  (about 
the  normal)  solution  of  salt. 

Salt  Solution. — As  advised  above,  this  is  a  10%  solution 
which  you  have  prepared  in  glass  flasks.  The  flasks  should 
be  wrapped  in  a  muslin  cover,  as  it  will  be  convenient  to  have 
the  outside  of  them  sterile.  They  are  best  sterilized  in  the  steam 
sterilizer  in  the  same  way  and  for  the  same  time  as  the  gauze 
and  muslin  supplies,  and  if  packed  carefully  they  may  be  done 
at  the  same  time. 

The  infusion  salt  solution  should  he  sterilized  hy  the  frac- 
tional method^  which  means  that  it  must  be  done  three  times  at 
24-hour  intervals,  and  between  sterilizations  it  must  be  kept  in 
a  warm  (80°  F.)  place.  The  process  each  time  will  be  the  same 
as  for  the  other  salt.  The  reason  for  this  special  treatment  is 
to  encourage  the  development  of  any  possible  spores  during  the 
interval  and  thus  bring  them  into  a  form  which  will  succumb  to 
the  next  sterilization.  Special  care  must  be  taken  to  see  that  these 
flasks  are  tightly  plugged  with  non-absorbent  cotton  as  otherwise 
the  water  will  evaporate  considerably  in  the  course  of  these  three 
sterilizations  and  render  the  solution  too  concentrated. 

Rubber  Dam. — This  is  used  chiefly  for  drains,  usually  the 
"cigarette"  drain  (see  Fig.  89,  page  310),  which  means  simply 
a  piece  of  the  rubber  rolled  around  a  strip  of  gauze  after  the 


250  TEXTBOOK  OF  SURGICAL  NUKSiNG 

fashion  of  a  cigarette.  It  is  the  better  practice  not  to  make  up 
this  drain  till  immediately  before  use  as  the  length  and  thick- 
ness will  need  to  be  adjusted  to  each  individual  "vvouud ;  and  as 
any  of  the  gauze  you  have  for  other  purposes  will  do  for  this 
one  you  will  simply  need  to  have  the  rubber  dam  in  readiness 
in  a  variety  of  sizes  varying  from  3  or  4  to  6  or  8  inches  square. 
The  pieces  should  be  well  washed  in  soap  and  Avarm  water,  and 
then  sterilized  hy  hoiling  in  plain  water  for  10  minutes.  This 
rubber  will  be  in  better  condition  for  use  if  boiled  freshly  at 
the  time,  but  when  it  is  used  frequently  it  is  a  good  practice  to 
boil  a  supply  in  advance  and  store  it  in  a  well-covered  glass  jar 
in  a  1-60  carbolic  solution.  This  solution  softens  the  rubber  in 
time,  so  no  more  should  be  prepared  than  will  be  used  within  a 
week  or  two. 

Rubber  Tissue. — This  should  be  cut  in  sizes  similar  to  those 
of  the  rubber  dam,  and  it  too  should  be  washed  in  soap  and 
water,  but  as  hot  water  dissolves  it  care  must  be  taken  to  use 
cool  water.  The  only  method  w^hich  can  be  used  for  sterilization 
of  rubber  tissue  is  the  chemical  one  and  the  best  solution  is 
bichloride  1-1000.  Naturally,  you  will  feel  that  by  this  method 
you  may  not  be  able  to  sterilize  the  tissue  beneath  the  surface 
since  it  is  made  of  rubber  and  is  therefore  impervious  to  any 
solution,  but  when  you  soak  it  over  night,  or  for  12  hours,  you 
may  feel  that  your  germicidal  solution  has  reached  any  part  of 
it  that  any  of  the  wound  fluids  will  be  able  to  do  and  that,  there- 
fore, it  is  fit  for  aseptic  surgical  use.  Necessarily  this  tissue 
must  be  prepared  in  advance,  and  after  it  has  been  subjected 
to  the  1-1000  solution  of  bichloride  for  12  hours  it  should  be 
stored  in  a  glass  jar  in  a  1-5000  solution  of  bichloride.  Do  not 
use  a  stronger  solution  than  the  1-5000  for  storage  because  the 
tissue  is  used  directly  from  this  solution  and  a  stronger  one 
wall  be  irritating  to  some  wounds.  Also,  do  not  use  a  carbolic 
acid  solution,  because  rubber  tissue  deteriorates  rapidly  in  it. 

Rubber  Tubing. — Whether  or  not  you  provide  a  sterile  sup- 
ply of  rubber  tubing  will  depend  upon  how  much  demand  you 
have  for  it.  Some  surgeons  use  it  considerably  for  drainage, 
and  in  that  case  it  is  well  to  have  a  sterile  supply  prepared  in 
advance.    Tubes  of  a  variety  of  diameters  will  be  needed,  and  a 


OPERATING  ROOM  STERILIZATION  251 . 

serviceable  length  for  each  piece  will  be  about  12  or  14  inches. 
After  being  well  washed  this  rubber  may  be  prepared  for  use 
in  one  of  several  ways :  It  may  simply  be  boiled  for  10  minutes 
and  then  stored  in  a  jar  of  1-60  carbolic  solution;  or,  after 
washing  it  may  be  boiled,  dried,  powdered,  and  sterilized  in 
muslin  covers  or  long  glass  tubes  in  the  steam  sterilizer.  The 
reason  for  boiling  this  tubing  before  steam  sterilization  is  the 
same  as  that  given  above  for  rubber  gloves,  namely,  to  remove 
the  surface  finish  which  the  manufacturer  has  put  upon  it  and 
which  becomes  soft  and  somewhat  sticky  under  the  steam.  The 
powder  serves  the  same  purpose  as  in  the  case  of  the  gloves, 
namely,  to  absorb  the  small  amount  of  this  gum  which  oozes 
to  the  surface  during  a  sterilization — before  use  this  powder 
must  be  rinsed  off  in  sterile  water.  Perhaps  the  most  practical 
plan  for  storing  this  tubing  is  in  the  long  glass  tubes  which  are 
sold  as  ' '  catheter ' '  tubes.  One  piece  in  a  tube  will  be  best,  and 
a  gauze-covered  absorbent  cotton  stopper  fastened  well  down 
over  the  mouth  of  the  tube  will  be  necessary  so  as  freely  to 
admit  the  steam  to  the  interior. 

Rubber  Aprons. — These  are  best  sterilized  as  advised  for  the 
rubber  gloves,  that  is,  they  are  well  powdered,  wrapped  in  a 
muslin  cover  and  sterilized  in  the  steam  sterilizer  as  directed 
for  the  gloves. 

Syringes. — Many  syringes  are  boilable  and  boiling  is  the  best 
method  where  permissible,  but  there  are  so  many  types  of 
syringe  that  one  must  make  sure  of  the  construction  of  each  one 
before  attempting  to  sterilize  it  because  the  wrong  method  will 
quickly  put  this  delicate  instrument  out  of  order.  An  all-metal 
one  which  has  perhaps  a  leather  or  rubber  plunger  or  packing, 
a  hard  rubber  one  or  one  with  hard  rubber  mountings,  and 
some  of  the  combination  glass  and  metal  ones  cannot  be  boiled 
and  must  be  sterilized  by  soaking  in  some  solution.  A  1-20 
carbolic  acid  solution  is  perhaps  a  good  all-round  one  for  such 
syringes,  as  bichloride  will  rust  the  metal  parts  and  alcohol 
will  injure  the  rubber  and  leather  parts.  A  plan  which  may 
be  applied  to  the  all-glass  one,  where  it  wall  be  an  advantage 
to  have  it  ready-sterilized,  is  to  put  it  (with  the  plunger  sepa- 
rated) into  a  cotton-plugged  glass  tube  and  sterilize  it  in  the 


252  TEXTBOOK  OF  SURGICAL  NURSING 

steam  sterilizer.  A  piece  of  cotton  will  be  needed  in  the  bottom 
of  this  tube  to  avoid  breakage. 

Thermometers, — The  chemical  method  will  always  be  neces- 
sary for  tlie  sterilizati(m  of  thermometers  and  any  solution  will 
answer,  though  bichloride  should  be  first  choice. 

Needles. — As  any  moist  method  of  sterilization  wall  soon 
rust  .syringe  needles  interiorly  a  good  plan  is  to  put  each  one 
into  a  small  glass  tube  plugged  with  cotton  and  sterilize  in  the 
dry  air  sterilizer  for  1  hour  at  300°  F.  The  "temper"  is  of 
course  somewhat  altered  by  this  process  but  it  is  not  enough 
to  be  seriously'  noticed,  and  the  needles  will  always  be  free  from 
rust  and  will  last  much  longer. 

The  suture  needles  may  he  boiled  with  the  instruments,  for 
although  they  come  under  the  classification  of  ' '  cutting ' '  instru- 
ments, which  we  shall  tell  you  a  few  paragraphs  hence  should 
not  be  boiled,  the  harm  done  to  them  is  so  little  as  to  be  negligi- 
ble. In  some  large  institutions  where  many  varieties  are  needed 
during  a  session,  it  is  the  practice  to  arrange  a  complete  set  in 
a  muslin  or  folded  towel  case  (Fig.  54)  and  sterilize  them  in  a 
cloth  cover  in  the  hot  air  sterilizer  for  1  hour  at  300°  F.  This 
high  temperature  and  the  subsequent  slow  cooling  somewhat 
soften  them,  however,  but  the  entire  avoidance  of  rust  and  the 
couA^enience  compensate  for  this  slight  objection. 

Tourniquet  and  Esmarch  Bandage. — Boil  15  minutes  in  nor- 
mal salt  solution. 

Vaseline,  Olive  Oil,  Glycerine. — These  may  all  be  sterilized 
in  the  steam  sterilizer  if  care  is  taken  to  put  them  into  containers 
that  w^ill  withstand  the  temperature.  Or,  a  method  of  second 
choice  is  to  boil  them  in  a  water  bath. 

Novocain. — This  will  withstand  a  moderate  amount  of  boil- 
ing in  a  water  bath. 

Instruments. — All  instruments  except  the  "cutting"  ones, 
such  as  knives,  are  sterilized  by  boiling  in  the  1%  washing  soda 
solution  for  not  less  than  10  minutes.  The  sharp-edged  ones  are 
somewhat  dulled  by  the  boiling  and  will  therefore  need  to  be 
sterilized  chemically.  Alcohol  is  much  used  for  this  purpose,  but 
the  objection  to  it  is  that  the  instruments  must  remain  in  it  an 
hour  or  two,  and  in  that  time  the  water  which  all  alcohol  contains 


OPERATING  ROOM  STBRTLTZATION 


253 


1 


K7- 

It  r, 
II  II 
1.  i' 

,t"l, 

''/ 1' 

^ 

''11'' 

V) 

Fig,  54.— Needle  Book.     Made  from  the  ordinary  draping  towel  or  a  piece 
of  muslin  folded  by  the  steps  indicated. 


254  TEXTBOOK  OF  SURGICAL  NURSING 

rusts  them  more  or  less.  Another  nietlioil  friMjuently  praetieed  is 
to  soak  these  instruniciits  in  pure  carbolic  acitl  i'or  5  minutes, 
rinse  off  the  earbolie  in  alcohol,  and  then  dry  them.  Rust  is 
avoided  in  this  way,  and  -when  the  instruments  are  free  from 
intricate  joints  or  crevices  from  Avliicli  the  earbolie  mij2:ht  chance 
not  to  be  removed  thoroughly  by  the  alcohol,  there  is  no  objection 
to  this  method.  Carbolic  solution,  1-20,  is  often  used  also,  bujt  it 
is  a  slow  germicide  and  involves  the  complication  of  rust.  In 
any  of  the  solutions,  however,  the  disadvantage  of  rust  may  be 
greatly  reduced  by  the  addition  of  a  few  grains  of  borax. 

The  hot  air  method  is  sometimes  used  for  the  sterilization  of 
instruments,  and  for  the  heavier  and  plainer  ones  there  seems 
to  be  no  harmful  result,  but  the  practice  will  play  havoc  with 
the  delicately  constructed  and  the  cutting  ones,  as  the  high 
degree  of  temperature  necessary  and  the  subsequent  cooling 
alter  the  "temper"  of  them  and  thereby  their  adjustment. 

Suture  Material. — In  most  cases  the  suture  material  wall  be 
purchased  ready-prepared,  but  as  the  nurse  may  wish  to  know 
the  various  processes  for  her  own  satisfaction,  and  as  she  may 
sometimes  be  called  upon  to  sterilize  the  various  materials  her- 
self, we  shall  give  here  a  few  of  the  more  frequently  employed 
methods. 

When  the  nurse  undertakes  the  sterilization  of  suture  mate- 
rial she  must  remember  that  she  is  dealing  with  the  most  serious 
piece  of  sterilization  which  she  will  ever  be  called  upon  to  do 
because  the  sutures,  especially  the  catgut  ones,  are  imbedded  in 
tissues  which  have  been  more  or  less  injured  by  the  operation 
and  thereby  made  more  susceptible  to  infection  and  they  will 
hold  there  in  this  very  good  culture  medium  any  germs  which 
may  have  escaped  destruction,  and  thus  bring  about  the  most 
serious  kind  of  infection.  Catgut  is  difficult  to  sterilize  by  any 
process  because  it  is  very  easily  ruined  by  even  slight  departure 
from  the  tried  and  true  methods  which  have  been  established  by 
very  exact  experimentation,  a  few  degrees  more  of  heat,  for 
instance,  making  it  so  brittle  that  it  will  crack  in  the  process  of 
tying  or  tear  under  any  slight  strain;  so,  before  attempting  the 
sterilization  of  catgut  the  nurse  must  make  sure  that  she  under- 


OPERATING  ROOM  STERILIZATION 


255 


stands  and  can  control  her  sterilizer  and  all  the  other  apparatus, 
and  that  she  has  an  intelligent  knowledge  of  the  formula  she 
is  using,  of  the  ends  at  which  she  is  aiming  in  each  step,  and  of 
the  final  result  she  must  get.  A  very  important  point  which 
she  must  settle  before  each  sterilization  is  that  she  is  using  a 
thermometer  which  is  absolutely  accurate,  because  faulty  and 
inaccurate  thermometers  are  responsible  for  more  failures  than 
any  other  defect  of  the  process.  The  person  who  does  this 
w^ork  must  give  her  undivided  attention  to  it  throughout  the 
process  or  she  will  not  escape  at  least  one,  or  more,  of  the  many 
pitfalls  which  lie  in  her  pathway. 

Plain  Catgut 

The  raw  catgut  is  manufactured  in  seven  and  sometimes  nine 
weights  and  is  usually  sold  in  bundles  of  ten  strands,  each  strand 
being  10  feet  in  length.  There  are  many  ways  advised  for 
arranging  it  before  sterilization 
and  most  of  them  are  con- 
venient and  technically  good, 
but  the  one  which  will  apply  to 
all  methods  is  that  of  cutting  it 
into  the  proper  size  for  use, 
which  will  mean  about  30 
inches  for  the  suture  and  15 
inches  for  the  ligature,  the 
strand  of  10  feet  thus  making  4 
sutures  or  8  ligatures.  These 
should  then  be  rolled  around 
the  fingers  into  coils  of  about 
11/2  inches  in  diameter,  the  end 
of  the  strand  being  wrapped 
around  the  finished  coil  to  pre- 
vent its  unrolling  (Fig.  55). 
The  most  economical  way  is  to  roll  each  suture  or  ligature  sep- 
arately, buit  of  course  any  number  which  is  found  convenient 
may  be  combined  into  one  coil.  This  plan  involves  so  much  less 
handling  after  sterilization  than  those  in  which  it  is  necessary 
to  cut  the  desired  piece  from  a  large  reel,  and  this  is  perhaps  the 


Fig.  55. — Method  of  Eolling 
A  Catgut  Suture  or  Ligature  for 
Convenient  Handling  in  Sterili- 
zation AND  IN  Dispensing  at  the 
Operating  Table.  The  ends  should 
be  coiled  about  the  roll  only  once 
or  twice,  as  more  turns  will  per- 
manently kink  it. 


256  TEXTBOOK  OF  SURGICAL  NURSING 

best  reason  one  can  advance  in  favor  of  any  method  of  steriliza- 
tion. 

There  is  an  almost  uncountable  numher  of  formula;  for  the 
preparation  of  catgut,  and  it  does  not  seem  to  matter  much  Avhich 
one  is  used  for  they  all  arrive  at  the  same  destination,  namely, 
sterile  catgut.  There  is  a  little  difference,  however,  in  some 
cases  in  the  texture  of  the  suture,  the  iodine  methods,  for 
instance,  having  a  tendency  to  make  it  a  little  less  flexible,  but 
aside  from  this  there  seems  to  be  no  reason  except  individual 
taste  for  preferring  anj'  one  of  the  following  to  any  other  one 
of  them. 

Lee  Method   (Modified). — 

1.  Line  metal  or  glass  beakers  loosely  with  heavy  filter 
paper,  so  as  to  insulate  the  catgut  from  the  walls  of  the  beaker 
which  gets  hotter  during  the  process  than  the  contents  and  will 
burn  the  catgut  at  any  point  of  contact.  ■ 

2.  Throw  coils  of  catgut  into  beaker  loosely. 

3.  Place  in  hot  air  sterilizer. 

4.  Raise  the  temperature  of  the  oven  slowly  to  212°  F.  and 
keep  it  there  for  40  minutes.  This  is  to  dry  out  the  catgut,  and 
it  should  therefore  be  done  on  a  dry  day  and  in  a  room  free 
from  abnormal  moisture. 

5.  Immediately  at  the  end  of  the  40  minutes  barely  cover 
the  catgut  with  liquid  albolene  which  has  been  heated  to  about 
120°  F. 

6.  Raise  the  temperature  of  the  sterilizer  slowly  and  gradu- 
ally to  300°  F.  and  keep  it  at  exactly  this  temperature  for  30 
minutes. 

7.  Leave  the  beakers  in  the  sterilizer  to  cool  slowly. 

8.  After  24  hours  heat  the  sterilizer  slowly  again  to  300°  F. 
and  keep  it  there  for  one  hour. 

9.  Allow  to  cool  as  before. 

10.  When  cold  drain  off  the  albolene  and  store  the  catgut  ha 
sterile  jars  in  a  1/16%  alcoholic  solution  of  iodine. 

11.  The  catgut  will  be  ready  for  use  in  24  hours. 

It  will  be  better  not  to  cover  the  beakers  during  the  process, 


OPERATING  ROOM  STERILIZATION  257 

which  will  be  perfectly  good  technie  since  the  sterilizer  is  not 
disturbed  during  the  24  hours.  It  should  not  be  necessary  to 
remind  the  nurse  that  the  catgut  must  be  transferred  from  the 
beakers  to  the  sterile  storage  jars  with  sterile  forceps, 

Bartlett  Method. — 

1.  String  the  coils  of  catgut  on  a  thread. 

2.  Suspend  them  in  glass  or  metal  beakers  from  a  cardboard 
or  other  cover  so  that  they  will  not  touch  the  beakers  at  any 
point.  The  reason  for  this  is  that  the  beakers  become  hotter 
in  the  process  than  their  contents  and  the  catgut  will  be  burned 
wherever  it  touches  the  beaker. 

3.  Insert  the  thermometer  into  the  center  of  the  beaker 
through  an  opening  in  the  cover. 

4.  Put  the  beakers  in  a  sand  bath  and  raise  the  temperature 
(within  the  beakers)  to  180°  F.  and  keep  it  there  for  1  hour; 
then  raise  the  temperature  gradually  to  220°  F.  and  maintain 
it  there  for  1  hour  more.     This  ii  to  dry  the  catgut. 

5.  Pour  on  enough  liquid  albolene  to  barely  cover  the  cat- 
gut. 

6.  Heat  very  slowly,  during  a  period  of  1  to  2  hours  to  212° 
F.  and  keep  it  at  that  temperature  for  12  hours. 

7.  At  the  end  of  12  hours  increase  the  heat  slowly,  through 
a  period  of  1  hour,  to  300°  F. 

8.  When  300°  F.  is  reached  immediately  turn  off  the  heat 
and  allow  the  temperature  to  decrease  to  212°  F. 

9.  Drain  off  the  albolene  and  store  the  catgut  in  sterile  jars 
in  a  solution  composed  of : 

Iodine  crystals 1  part 

Columbian  spirits 100  parts 

10.  The  catgut  is  ready  for  use  in  24  hours. 

Claudius  Method. — 

1.     Place  the  catgut  in  a  jar  of  this  solution : 

Iodine  crystals  ......       1  part 

Potassium  iodide 1  part 

Distilled  water 100  parts 


258  TEXTBOOK  OF  SURGICAL  NURSING 

2.  Cover  the  jar  tightly  and  h't  it  stand  for  8  days. 

3.  After  the  eight  days  the  catgut  va.ay  either  be  left  in  the 
above  solution  or  stored  in  alcoliol. 

4.  Rinse  the  eatgut  in  sterile  water  before  use. 

BuRMEiSTER  jMethod. — Soak  the  catgut  for  one  week  in  this 
solution : 

Chloroform 1  gram 

Metallic  iodine 15  c.  c. 

BOECKMANN    METHOD. 

1.  Soak  catgut  in  ether  for  1  week. 

2.  Wrap  in  paraffine  paper  and  seal  in  a  paper  envelope. 

3.  Sterilize  in  dry  air  sterilizer  at  300°  F.  for  3  hours. 

4.  Repeat  sterilization  after  24  hours. 

New  York  Hospital  Method. — 

1.  Soak  in  benzine  24  hours. 

2.  Allow  benzine  to  dry  off. 

3.  Boil  in  alcohol  for  from  1  to  II/2  hours,  according  to  the 
weight  of  the  catgut. 

4.  Leave  catgut  in  the  alcohol. 

5.  After  24  hours  boil  again  for  %  hour. 

6.  Store  in  alcohol. 

Great  care  must  be  taken  when  boiling  alcohol  to  do  it  always 
in  a  double  boiler  or  sand  bath,  as  alcohol  is  easily  ignited, 
especially  when  an  open  flame  is  used. 

Chromic  Catgut 

As  stated  above,  chromic  catgut  is  plain  catgut  which  has 
been  hardened  in  a  solution  of  chromic  acid  to  make  it  resist 
absorption  in  the  tissues  longer. 

The  chromicizing  must  he  done  before  the  catgut  is  sterilized 
and  before  the  long  strands  are  cut.  The  reasons  for  this  will 
be  found  in  the  following  facts:  (a-)  The  chromic  acid  is  made 
up  wdth  water  whieh  renders  the  catgut  spongy  and  which  must 
be  dried  out  of  it  before  anything  further  can  be  done;  (6)  In 


OPERATING  ROOM  STERILIZATION  259 

the  process  of  dryiny  there  is  a  certain  amount  of  shrinkage 
which  takes  place  very  unevenly  unless  tlie  strands  are  kept 
stretched  during  the  process;  (c)  Consequently,  the  strands 
must  be  stretched  out  at  full  length  across  a  large  frame  or 
between  two  wall  pegs,  and  securely  fastened  at  Ijoth  ends  under 
moderate  tension  for  drying;  (d)  It  is  easier  and  simpler  to 
handle  the  long  strands  than  the  short  ones  for  this  part  of  the 
process. 

Therefore,  to  chromicize  the  catgut  we  lay  the  rolls  as  they 
come  from  the  factory  in  a  dish  which  will  allow  them  to  lie 
loosely  on  the  bottom  without  cramping,  and  then  pour  over 
them  a  1-2000  chromic  acid  solution,  and  leave  them  undisturbed 
in  this  solution  for  24  hours.  At  the  end  of  this  time  we  remove 
one  strand  at  a  time  and  stretch  it  carefully  and  at  an  even  and 
quite  moderate  tension  across  the  frame  or  between  the  pegs, 
fastening  both  ends  securely  because  there  is  considerable 
shrinkage  in  drying  and  therefore  a  strong  pull  on  the  ends. 
The  strands  may  be  separated  without  difficulty  if  the  precaution 
is  taken  before  putting  them  to  soak  to  examine  the  roll,  as  one 
would  a  skein  of  yarn,  to  see  in  which  direction  it  may  be 
unwound,  and  then  to  place  it  in  the  jar  accordingly.  It  is 
left  on  the  frame  until ' '  bone-dry ' '  and  is  then  sterilized  like  the 
plain  catgut. 

Kangaroo  Tendon 

This  is  prepared  like  the  catgut. 

Horsehair 

This  must  be  thoroughly  cleansed  in  soap  and  water,  and  it 
should  be  allowed  to  soak  in  this  for  a  few  hours  in  order  to  be 
sure  that  it  is  perfectly  clean.  It  is  then  rolled  into  coils  like 
the  catgut,  sterilized  hy  boiling  in  clear  water,  and  is  then  best 
stored  in  a  1-60  solution  of  carbolic  acid.  Because  of  the  special 
danger  of  tetanus  and  anthrax  spores  in  the  case  of  horsehair, 
sterilization  of  fresh  supplies  must  be  very  thorough,  an  hour 
or  more  being  required  for  safety.  The  horsehair  will  withstand 
this  amount  of  exposure  to  boiling  and  we  therefore  have  no 
excuse  for  giving  it  less.    Alcohol  is  sometimes  used  instead  of 


260  TEXTBOOK  OF  SURGICAL  NURSING 

carbolii'  for  storape  but  this  is  likely  to  make  it  too  stiff  and 
soniewliat  brittle. 

Silk  and  Linen  Thread 

These  must  be  Avound  (ni  small  reels,  i)referably  glass  ones, 
and  it  will  be  more  practical  for  future  use  to  leave  them  in  one 
long-  piece  rather  than  to  cut  them  into  suture  lengths.  If  tliey 
are  white  and  it  is  desired  to  dye  them  black  any  standard  fast 
dye  may  be  used  if  tlie  nurse  first  familiarizes  herself  Avitli  the 
correct  process  for  doing  this. 

Silk  and  linen  thread  are  sterilized  hy  boiling  in  plain  water 
and  should  not  be  subjected  to  the  process  for  more  than  30 
minutes,  as  they  deteriorate  somewhat  in  boiling  water. 

Sometimes  the  silk  thread  may  be  impregnated  with  paraffine 
or  with  liquid  albolene.  When  paraffine  is  used  it  should  either 
be  first  melted  and  the  silk  then  boiled  in  it,  or  a  jar  containing 
the  silk  and  enough  of  the  paraffine  to  cover  it  when  melted  may- 
be placed  in  the  autoclave  and  sterilized  like  the  gauze  dressings. 
When  boiling  paraffine  over  a  flame  or  a  stove  it  must  be  closely 
watched  as  it  will  burn  if  allowed  to  become  too  hot.  Albolene, 
also,  may  either  be  boiled  or  sterilized  in  the  autoclave,  and  it 
will  need  the  same  care  as  the  paraffine  when  boiled  on  a  stove 
or  open  flame. 

Silkworm  Gut 

The  raw  silkworm  gut  will  usually  be  supplied  by  the  market 
in  bundles  of  100  strands  each  about  14  or  15  inches  long.  These 
may  be  wound  in  coils  of  one  or  more  strands  each  like  the  cat- 
gut. It  is  usually  sold  in  the  natural  color,  white,  and  if  it  is 
preferred  black  it  vhslj  be  d.yed  as  suggested  for  the  silk  and 
linen.  This  is  best  done  after  it  has  been  rolled  into  the  coils. 
It  is  then  sterilized  hy  toiling  in  clear  water,  and  unlike  the 
silk  and  linen,  it  does  not  deteriorate  in  boiling,  so  a  generous 
amount  of  time  may  be  given  it.  It  should  then  be  stored  in 
a  1-60  carbolic  acid  solution.  Alcohol  should  not  be  used  for 
this  storage,  as  silkworm  gut  has  a  tendency  on  its  own  account 
to  be  brittle  and  alcohol  Mill  encourage  this  tendency  too  much. 


OPERATING  ROOM  STERILIZATION  261 

Some  lots  of  raw  silkworm  gut  will  be  inelined  to  crack  and 
splinter  when  rolled  into  the  coils,  and  in  this  case  it  should  be 
soaked  in  water  for  an  hour  or  tAvo,  which  will  render  it  very 
pliable. 

Silver  and  Aluminum-Bronze  Wire 

These  may  he  boiled  any  length  of  time  in  clear  water.  As 
they  are  infrequently  used,  and  as  they  are  so  easily  sterilized, 
it  is  not  necessary  to  keep  a  sterile  supply  of  them  ahead. 

Metal  Clips 

These  are  treated  the  same  as  the  wire. 

Factory-Prepared  Suture  Material  in  Glass  Tubes 

The  factory-prepared  suture  material  is  usually  put  up  in 
hermetically  sealed  tubes  (Fig.  56).  Some  of  these  tubes  may  be 
sterilized  hy  hoiling,  but  some  may  not ;  so,  before  attempting  to 
boil  any  of  them  it  must  be  de- 
termined whether  or  not  it  is 
safe  —  the  manufacturer  will 
usually  caution  against  boiling 
if  it  injures  his  product  in  any 
way.  Besides  the  fact  that  boil- 
ing the  tube  sometimes  ruins  the 
contents  there  is  the  danger  with 
any  tube  that  it  may  explode  in 
the  sterilizer.  AVe  have  seen  this 
happen  with  a  rather  serious  re-  Fig.   56.— Factory-prepared 

suit  on  an  occasion  when  a  large  gUss'tube^'^''""'"^'^'^^  ^^'^'^^'' 
number  of  the  tubes  were  being- 
boiled  together  and  the  most  of  them  were  suddenly  blown  out  of 
the  boiler  with  a  loud  report,  carrying  a  heavy  cover  before 
them,  and  scattering  themselves  in  hundreds  of  pieces  about  the 
room.  However,  boiling  of  these  tubes  is  a  very  common  practice 
and  it  is  very  convenient,  but  the  precaution  should  alwaj^s  be 
taken  to  wrap  them  in  a  cloth  cover  as  this  will  prevent  the 


262  TEXTBOOK  OF  SURGICAL  NURSING 

probability  of  Iheir  bring  t'rai'ked  by  being  knocked  about  iu 
vigoronsly-b oiling  ^\•alel^  Avliit'li  is  i)robably  about  tbe  only  cause 
of  tbe  explosion. 

A  perfectly  safe  "way  to  sterilize  these  tubes  is,  of  course,  the 
chemical  one.  It  does  not  matter  much  which  particular  chem- 
ical is  selected  as  long  as  perfect  sterilization  is  secured. 


CHAPTER  XVI 
THE    OPERATING    ROOM    IN    ACTION 

PREPARATION  OF  THE  ROOM  FOR  THE  OPERATION 

You  now  know  in  a  general  way  how  to  provide  what  you  are 
likely  to  need  for  the  average  operation,  and  we  can  proceed  to 
the  detailed  preparation  of  a  room. 

First  of  all,  absolute  cleanliness  of  the  room  in  every  respect 
must  be  attended  to.  Doors  and  windows  must  be  so  adjusted  as 
to  prevent  draughts  and  the  entrance  of  dust,  and  the  tempera- 
ture regulated  at  about  75°  or  76°  F. 

The  glass  and  other  articles  which  must  be  sterilized  chem- 
ically are  ''put  to  soak"  (the  bichloride  tub  which  we  advised 
above  will  serve  well  here)  ;  the  various  odds  and  ends  and  the 
parcels  of  sterile  supplies  which  will  be  needed  for  the  particu- 
lar case-  are  placed  in  convenient  readiness;  boilers  are  filled 
with  the  articles  which  belong  in  them  and  are  started  boiling; 
and  you  then  proceed  to  the  sterilization  of  your  hands. 

This,  of  course,  you  will  do  in  the  dressing  room.  First,  you 
will  put  on  your  cap  and  mask,  as  you  cannot  do  it  safely  after 
your  hands  are  sterile,  and  no  one  else  can  do  it  satisfactorily 
for  you.  Next,  you  scrul)  your  hands  and  arms  by  means  of  a 
brush,  green  soap,  and  warm  running  water,  scrubbing  from 
the  elbows  downward  and  continuing  the  process  carefully  and 
painstakingly  for  at  least  5  minutes,  taking  special  care  to  clean 
thoroughly  about  the  nails  with  the  nail  cleaner.  The  brush  and 
nail  file  you  have  previously  boiled  and  brought  to  the  dressing 
room  in  a  small  sterile  basin  of  alcohol,  a  1-60  carbolic  solution, 
or  any  other  suitable  solution.  The  scrubbing  completed,  you 
will  continue  the  sterilization  of  your  hands  by  some  such  method 
as  these:  (a)  Rinse  off  the  soap  thoroughly,  allowing  the  water 
to  run  from  the  hands  toward  the  elbows  rather  than  in  the  oppo- 
site direction  so  as  to  avoid  the  possibility  of  rinsing  contamina- 

263 


264  TEXTBOOK  OF  SURGICAL  NURSING 

tiou  from  the  iimvashed  upper  arm  dowmvard  over  the  hands; 
rinse  in  ak-oliol ;  and  then  innnerse  the  arms  and  liands  in  a 
1-1000  solution  of  bichloride  fen-  3  minutes.  When  bichloride  is 
used  the  greatest  care  must  alwaj^s  be  taken  to  have  absolutely 
all  tlie  soap  removed  as  bichloride  cannot  penetrate  it  and  there- 
fore will  never  reach  the  skin,  (h)  After  rinsing  put  a  small 
quantity  of  chloride  of  lime  and  the  same  amount  of  powdered 
washing  soda  into  the  palm  of  j^our  hand,  make  a  lather  of  this 
with  a  little  water  and  rub  the  arms  and  hands  witli  it  for  a 
minute  or  two ;  then  rinse  this  off  in  a  basin  of  sterile  water  and 
immerse  the  arms  and  hands  in  the  bichloride  for  3  minutes. 

There  are  manj^  other  methods  which  you  may  learn  from  time 
to  time,  but  these  two  are  as  thoroughgoing  and  as  convenient 
as  any. 

You  now  put  on  the  sterile  gown,  having  some  unsterile  person 
fasten  it  for  you,  and  you  are  ready  to  go  into  the  operating 
room. 

All  of  the  tables  whicli  are  to  be  used  for  sterile  supplies  have 
been  '^dusted"  with  a  towel  wrung  out  of  bichloride  solution. 
If  you  have  an  unsterile  assistant  she  may  do  this  for  you,  or 
you  may  have  done  it  previously  yourself.  The  practice  of  doing 
this  after  the  sterile  gown  has  been  put  on  is  not  technically 
good  as  there  are  too  many  chances  of  its  being  unsterilized  in 
the  process. 

Your  next  step  is  to  drape  the  tables  with  the  sterile  towels, 
and  to  put  upon  them  the  sterile  supplies  which  you  have  boiled 
or  otherwise  sterilized.  In  draping  tables  it  h  a  good  practice 
to  cover  them  first  with  towels  wrung  out  of  the  bichloride  solu- 
tion, as  the  wet  towels  stay  in  place  better  than  the  dry  ones, 
and  more  than  one  laj^er  of  cover  should  always  be  used  on  a 
sterile  table  because  there  may  often  be  unnoticed  holes  in  the 
towels.  The  supplies  should,  of  course,  be  kept  well  covered  with 
towels  or  a  suitable  sheet. 

There  are  innumerable  details  in  connection  Avith  the  arrange- 
ment of  the  various  supplies  such  as  suture  material,  instru- 
ments, etc.,  but  a  large  volume  would  be  required  to  record  them 
all,  and  then  it  would  be  impossible  to  provide  for  all  the  varia- 
tions that  will  be  dictated  from  time  to  time  by  the  arrangement 


THE  OPERATING  ROOM  IN  ACTION  265 

of  the  room,  the  nature  of  the  operation,  etc.  If  you  use  the 
drums  for  your  supplies  your  task  will  be  relatively  simple, 
but  you  will  always  need  to  draw  upon  your  ingenuity  in  oper- 
ating room  work,  and  if  you  have  given  careful  attention  to 
your  training  up  to  this  point  you  should  now  be  able  to  adapt 
your  methods  to  any  given  average  set  of  conditions. 

We  shall  now  assume  that  you  are  ready  for  the  patient. 

The  anesthetizing  room  should  be  in  complete  readiness  as  to 
supplies  needed  there,  temperature,  etc.,  and  the  precaution 
should  always  be  taken,  where  possible,  to  have  this  room  so 
closed  off  from  the  operating  room  that  the  patient  will  not  be 
subjected  to  the  sometimes  terrifying  sight  of  the  preparation 
you  have  made  for  him.  Of  course,  when  the  operating  room 
must  serve  also  as  the  anesthetizing  room  this  cannot  be 
managed. 

In  the  chapter  on  anesthesia  (Chapter  XIII)  the  care  of  the 
patient  has  been  discussed,  so  we  shall  not  give  that  here. 

After  the  patient  has  been  anesthetized  the  next  steps  will 
be  to  arrange  him  in  the  proper  position  for  his  operation,  to 
sterilize  the  operative  field,  and  then  to  apply  the  sterile  draping 
sheets  and  towels.  In  some  cases,  wdien  gas  or  gas  and  oxygen 
are  the  anesthetics  used,  the  patient  may  be  entirely  prepared 
and  draped  before  the  anesthetic  is  administered,  but  this  prac- 
tice is  likely  to  be  very  hard  for  the  patient  to  undergo,  and 
it  is  usually  unsatisfactory  because  of  the  fact  that  the  position 
and  the  draping  are  usually  more  or  less  disarranged  by  the 
struggling  of  the  patient  which  is  always  attendant  upon  the 
induction  of  any  anesthesia. 

PREPARATION  AND   STERILIZATION  OF   THE   OPERATIVE 

FIELD 

How  this  is  done  will  depend  upon  the  part  to  be  sterilized 
and  upon  the  surgeon's  preference  of  method.  (For  further 
detailed  discussion  of  the  preparation  of  the  operative  field  see 
treatment  of  particular  cases  in  Chapters  IV-XI.)  At  this  writ- 
ing the  prevailing  practice,  as  far  as  the  operating  room  is  con- 
cerned, is  to  have  the  part  dry-shaved  and  then  to  paint  it  with 


266  TEXTBOOK  OF  SURGICAL  NURSING 

iodine,  sometimes  preceding  the  iodine  with  a  sponging  with 
ether.  As  a  rule  the  shaving  will  have  to  be  done  before  the 
patient  comes  to  the  operating  room,  and  this  is  the  better 
technic.  The  point  that  all  parts  which  are  to  be  painted  with 
iodine  should  be  perfectly  dry  must  not  be  overlooked,  because 
it  is  a  fact  that  the  iodine  does  not  penetrate  as  deeplj'  into  skin 
that  has  been  recently  wet  as  it  does  into  the  normally  dry  skin, 
and  furthermore,  it  is  believed  that  the  presence  of  an  abnormal 
amount  of  water  in  the  skin  renders  it  more  susceptible  to  the 
somewhat  irritating  power  of  the  iodine.  This  means  that  all 
operating  room  shaving  will  be  done  dry,  because  it  is  perhaps 
not  overcautious  to  make  the  rule  that  the  lather  should  not  be 
used  within  the  12  hours  preceding  the  iodine  application. 

Some  parts  of  the  hody,  the  face  for  instance,  as  a  rule  are 
not  subjected  to  the  iodine,  but  instead  are  scrubbed  with  green 
soap  and  rinsed  with  alcohol  and  perhaps  also  with  bichloride. 
For  children,  old  people,  or  others  whose  skin  might  be  too  much 
irritated  by  the  full-strength  tincture  of  iodine,  it  is  diluted  to 
half  strength,  and  sometimes  less,  by  the  addition  of  alcohol. 

A  simple  way  to  apply  the  iodine  is  by  means  of  a  small  gauze 
sponge  held  in  a  pair  of  forceps,  preferably  sponge  forceps,  but 
care  must  always  be  taken  not  to  use  so  much  iodine  that  it  will 
trickle  down  under  the  patient's  body  or  into  the  axilla  or  any 
other  part  where  it  may  be  confined  in  the  presence  of  moisture 
and  cause  troublesome  burns.  Sometimes  the  iodine  will  be 
sponged  off  with  alcohol  immediately  after  it  has  thoroughly 
dried. 

OPERATIVE  POSITIONS  AND  DRAPING 

It  is  something  of  an  art  to  arrange  the  patient  in  a  good  and 
stable  position  and  to  place  the  sterile  draping  so  that  it  will 
be  unobtrusive  and  at  the  same  time  serviceable  and  durable. 
Anyone  can  lay  towels  and  sheets  around  an  operative  field,  but 
it  takes  study  and  ingenuity  to  do  it  well.  Likewise,  there  are 
many  points  about  the  various  positions  of  the  patient,  which, 
to  be  appreciated,  must  be  studied  and  practiced  carefully. 

"We  shall  now  take  up  the  representative  operative  positions 
and  the  sterile  draping  suitable  for  them.    When  not  definitely 


THE  OPERATING  ROOM  IN  ACTION 


267 


mentioned  it  will,  of  course,  be  understood  that  the  operative 
field  has  heen  sterilized  immediately  after  the  position  has  been 
arranged  and  before  the  sterile  draping  is  adjusted. 

Also,  as  it  will  be  monotonous  to  mention  it  each  time,  we  shall 
here  lay  down  the  rule  that  a  rubber  sheet  will  be  thrown  over 
the  patient,  table,  sandbag,  etc.,  in  any  place  where  there  is 
likely  to  be  much  drainage  from  the  operative  field. 

Dorsal  Position. — This  is  the  most  frequently  employed  po- 
sition (Fig.  57),  and  it  will  be  used  for  most  operations  upon  the 
intestines,  stomach,  pancreas,  spleen,  and  bladder.     In   some 


Fig.  57. — Dorsal  Position.  The  pillows  under  the  back  and  thighs  are 
for  the  greater  comfort  of  the  patient  and  for  the  relaxation,  of  the  ab- 
dominal muscles. 


cases  the  patient  is  simply  placed  flat  upon  the  back,  but  in 
others  there  will  be  a  small  pillow  under  the  ''small"  of  the 
back  and  a  larger  one  or  a  small  sandbag  under  the  thighs  as 
shown  in  the  illustration.  The  pillow  under  the  back  will  be 
especially  desirable  for  women,  whose  backs  naturally  curve 
more  than  men's,  and  it  will  serve  the  purpose  of  preventing 
the  severe  backache  which  so  frequently  complicates  convales- 
cence from  a  long  abdominal  operation,  because  it  keeps  the 
muscles  of  the  back  in  their  natural  position  and  prevents  the 
abnormal  strain  which  would  otherwise  occur.  The  pillow  under 
the  knees  causes  relaxation  of  the  abdominal  muscles  which 
results  in  much  less  strain  upon  them  and  thus  enables  the  sur- 


268 


TEXTBOOK  OF  SURGICAL  NURSING 


geon  to  retract  tliem  out  of  his  way  more  easily  and  with  less 
injury  to  them  when  doing  an  abdominal  operation.  The  arms 
may  be  arranged  in  various  ways  but  these  two  will  answer  all 
purposes  for  this  position:  («)  They  may  be  fastened  at  the 
patient's  side  by  means  of  a  folded  towel  (Fig.  58),  w^hieh  is 
passed  across  the  table  under  the  joatient's  back  and  an  end 
pinned  about  each  forearm,  or  an  end  turned  over  each  arm  and 
then  lucked  under  the  patient's  body.  (&)  They  maj'  be  laid 
against  the  chest  Avith  the  hands  well  outward  on  the  shoulders 


Fig.  ^8. — AIe'ihuu  of  J-'astexing  the  Arms  at  the  Patient's  Side. 
The  towel  is  passed  under  the  patient 's  body  crosswise  of  the  table,  and  the 
end  is  carried  around  the  wrist  and  then  tucked  under  the  body. 

(Fig.  59),  the  sleeve  pinned  to  the  shoulder  of  the  gown,  and 
the  tail  of  the  gown  tucked  about  them  to  hold  them  in  place. 
The  arms  are  less  obtrusive,  as  a  rule,  when  hnng  at  the  patient's 
side,  but  there  are  many  operations  in  which  this  practice  is 
technically  quite  unrefined,  for  instance,  abdominal  or  other 
trunk  cases  in  which  pus,  irrigating  solutions,  etc.,  may  run 
down  over  the  arms  and  hands  thus  placed. 

The  sterile  draping  for  this  position  is  relatively  simple  and 
is  done  in  one  of  two  ways:  (a)  The  laparotomy  sheet  described 
on  page  227  is  laid  over  the  patient  very  carefully  (Fig.  60), 
two  people  being  almost  necessary  for  this  act  in  order  not  to 


THE  OPERATING  ROOM  IN  ACTION 


269 


run  the  risk  of  dragging  the  sheet  over  the  patient  and  thus 
unsterilizing  it  underneath  in  parts  which  may  later  be  drawn 
up  into  the  operative  field.     There  are  several  fancy  ways  in 


Fig.  59. — Method  of  Fastening  the  Arm>s  ox  tiik  Chest.  The  sleeve 
of  the  gown  is  pinned  well  outward  on  the  shoulder,  and  the  tail  of  the  gown 
is  then  brought  up  over  the  arms  and  securely  tucked  under  the  patient's 
body. 


Fig.  60. — Laparotomy  Sheet  in  Place  for  an  Abdominal  Operation. 
If  the  opening  in  the  sheet  is  larger  than  necessary  for  the  particular  ease 
this  sheet  may  be  supplemented  with  towels  as  shown  in  Fig.  61. 


which  this  sheet  is  sometimes  folded  before  sterilization  so  that 
one  person  can  apply  it,  but  they  require  a  great  deal  of  time, 
and  as  there  is  always  more  than  one  person  sterile  for  any 


270 


TEXTBOOK  OF  SURGICAL  NURSING 


Fig.  61.— Draping  for  the  Dorsal  Position  with  Two  Sheets  and 
Pour  Towels.  One  sheet  is  laid  across  the  lower  part  of  the  table  and  the 
edge  brought  up  to  the  lower  border  of  the  operative  field,  and  the  other 
over  the  chest  similarly.  The  towels  are  then  disposed  over  these  as  illus- 
trated, the  crosswise  towels  lying  on  top  of  the  lengthwise  ones  for  greater 
security.  One  of  the  towel  clamps  shown  in  Fig.  82  binds  these  towels  and 
the  underlying  sheets  securely  together  at  each  corner  of  the  operative  field. 


Pjq_  62. — Two  Types  of  Towel  Clamps,  Used  foe  Holding  the  Drap- 
ing Sheets  and  Towels  Together.  The  sharp-pointed  clamp  is  usually 
passed  through  the  patient's  skiii  as  well  as  the  draping. 


THE  OPERATING  ROOM  IN  ACTION 


271 


Fig.  63. — Trendelenburg  Position.  The  pillows  under  the  patient's 
back  and  thighs  serve  the  same  purpose  as  in  the  dorsal  position  (Fig.  57). 
The  shoulder  guard,  shown  more  clearly  in  Fig.  64,  keeps  the  patient  from 
sliding. 


Fig.  64. — Shoulder  Guard  for  Keeping  the  Patient  in  Place  in 
THE  Trendelenburg  Position.  The  guard  is  made  entirely  of  metal,  and 
as  it  sometimes  injures  the  patient 's  shoulder  it  is  advisable  to  wrap  it 
with  cotton  and  a  bandage  as  has  been  done  to  this  one. 


272 


TEXTBOOK  OF  SURGICAL  NURSING 


operation  Avliere  this  sheet  will  be  appropriate  an  assistant  can 
always  be  found ;  or,  if  carefully  done  there  can  be  no  objection 
to  an  unsterile  person  handling  the  end  which  is  placed  under 
the  patient's  chin  because  this  is  unsterilized  immediately  in 
any  case.  (6)  Tioo  sheets  and  i  towels  may  be  arranged  as  in 
Fig.  61.  It  should  be  noticed  that  the  towels  which  run  length- 
wise of  the  patient  are  put  on  first  and  the  crosswise  ones  laid 
over  them,  because  this  is  the  much  more  secure  way  and  it 
brings  the  towel  edges  into  positions  where  they  will  be  less 


Fig.  65. — Gall  Bladder  Position.  This  table  has  a  crosswise  rest  which 
may  be  screwed  up  under  the  gall  bladder  region  so  as  to  throw  it  well 
upward.  In  lieu  of  this  a  small  sandbag  will  serve  the  purpose.  See  also 
Fig.   66. 


likely  to  cause  annoyance  by  catching  upon  instruments  or  by 
being  brushed  out  of  place  by  the  arms  of  the  surgeon  and  assist- 
ants. The  two  crosswise  towels  will  keep  the  draping  in  place 
much  better  if  they  are  wet,  but  if  the  operative  field  has  been 
painted  with  iodine  there  may  be  objections  raised  to  the  use 
of  wet  towels  here.  A  towel  clamp  (Fig.  62)  or  some  substitute, 
such  as  an  ordinary  artery  clamp,  will  be  needed  at  each  of  the 
four  corners  of  the  field  to  keep  the  draping  in  place. 

Trendelenburg  Position. — For  this  position  (Fig,  63),  the 
patient  is  first  placed  in  the  dorsal  position,  the  foot  section  of 
the  table  is  dropped,  and  the  whole  table  top  is  then  inclined, 


THE  OPERATING  ROOM  IN  ACTION 


273 


with  the  foot  upward,  at  an  angle  of  45°  or  less,  care  having 
been  taken  to  have  the  patient's  knees  exactly  opposite  the 
hinge  of  the  footpiece.  It  will  be  necessary  to  have  the  patient 
braced  in  some  way  at  the  shoulders  so  as  to  prevent  his  slipping 
downward.  All  the  better  tables  will  have  shoulder  guards 
(Fig.  64)  for  this  purpose,  but  in  their  absence  sandbags  will 
serve  well. 

The  pillows  under  the  back  and  knees  will  serve  the  same 
purpose  here  as  in  the  dorsal  position.  The  hands  and  arms  will 
be  arranged  as  for  the  dorsal  position. 


Fig.  66. — Gall  Bladder  Position.  This  particular  table  can  be  broken 
under  the  gall  bladder  region  so  as  to  accomplish  the  purpose  of  the  rest 
shown  in  Fig.  65. 

This  position  will  be  used  in  gynecological  or  other  pelvic 
operations  as  it  causes  the  intestines  to  gravitate  out  of  the  way 
and  also  brings  the  pelvic  contents  up  from  the  bony  cavity  in 
which  they  would  otherwise  be  more  or  less  inaccessible. 

The  draping  is  the  same  as  for  the  dorsal  position. 

On  page  411  is  illustrated  a  method  for  improvising  this  posi- 
tion when  without  the  convenience  of  the  special  table. 

Gall  Bladder  Position. — In  some  cases  the  dorsal  position  will 
answer  for  operations  upon  the  gall  bladder,  but  oftener  the 
region  will  have  to  be  thrown  upward  (Fig.  65)  so  as  to  bring 


274 


TEXTBOOK  OF  SURGICAL  NURSING 


the  organ  out  from  under  the  ribs.    If  your  table  is  not  supplied 
with  the  ' '  rest ' '  shown  in  the  illustration  a  pillow  or  small  sand- 


FiG.  67. — Kidney  Position.  A,  rear  view  showing  the  disposal  of  the 
one  arm  and  the  elevation  of  the  patient's  waist  line  to  about  the  level  of 
the  hips;  B,  front  view  showing  where  the  other  arm  rests  and  how  the 
sandbags  are  best  placed  for  stabilizing  the  patient  in  the  proper  position, 
which  is  slightly  forward  of  the  true  lateral  position. 

bag  will  answer  the  purpose;  or,  you  may  have  a  table  which 

can  be  broken  in  the  middle  directly  under  the  gall  bladder 

region  (Fig.  66)  which  will  accomplish  the  same  purpose. 


THE  OPERATING  ROOM  IN  ACTION  275 

The  draping  will  be  the  same -as  for  the  dorsal  position. 

Kidney  Position. — The  patient  is  turned  on  his  side  (Fig. 
67)  with  the  lower  arm  at  his  back,  the  other  up  toward  his  face, 
the  uppermost  knee  and  hip  joints  flexed  so  as  to  bring  the  knee 
down  upon  the  table  in  the  capacity  of  a  brace  to  keep  the  body 
from  falling  forM^ard,  the  chest  is  braced  anteriorly  with  a  large 
sandbag,  and  sometimes  the  pelvis  also  will  need  the  support 
anteriorly  of  a  heavy  sandbag.  The  crosswise  rest  is  now 
screwed  upward  directly  under  the  location  of  the  kidney  so 


Fig.  68. — Prone  Position.  The  patient  lies  flat  upon  his  face  except 
for  one  shoulder  which  is  elevated  slightly  upon  a  small  sandbag  so  as 
to  turn  his  face  away  from  the  table  sufficiently  for  the  administration  of 
the  anesthetic.  Some  tables  may  be  broken  at  the  head  so  as  to  accomplish 
this  purpose  without  the  sandbag,  or,  the  arrangement  shown  in  Fig.  83 
may  be  used. 


as  to  throw  the  organ  as  well  outward  and  upward  as  necessary 
from  under  the  ribs.  Foresight  should  be  used  in  seeing  that 
the  patient  is  properly  placed  in  relation  to  this  rest  before  any 
of  the  preceding  adjustments  are  made  so  that  the  raising  of  it 
will  not  disarrange  the  position.  When  properly  arranged  the 
patient  will  incline  very  slightly  toward  his  face  from  the  true 
lateral  position. 

This  is  the  most  difficult  position  to  arrange  and  a  great  deal 
of  practice  should  be  devoted  to  it  by  the  beginner. 

The  draping  corresponds  to  that  for  the  dorsal  position. 

Prone  Position. — The  patient  lies  flat  upon  the  table  with  the 
face  downward  and  the  arms  above  the  head  (Fig.  68).     Spe- 


276 


TEXTBOOK  OF  SURGICAL  NURSING 


cial  care  of  the  head  must  be  taken  in  an-aiiyin«j;  this  position; 
some  tables  will  be  so  constructed  that  a  section  at  the  liead  may 
be  lowered  somewhat  to  allow  the  patient's  head  the  required 


^^Sim 


Fig.  69. — LATEKo-i'KnXK  I'dsiTiox.  The  patient  is  inclined  about  half 
way  between  the  lateral  and  the  prone  positions,  and  tlie  sandbags  under 
the  chest  and  the  hips,  and  his  flexed  knees,  stabilize  him. 


Fig.  70. — Eeversed  Tkendelenburg  Position. 


room,  but  in  place  of  this  a  small  pillow  or  sandbag  may  be 
placed  under  one  shoulder. 

This  position  will  be  used  for  operations  upon  the  spine  or 
other  parts  of  the  back. 

The  dorsal  draping  may  be  adapted  to  this  position. 


THE  OPERATING  ROOM  IN  ACTION 


277 


Fig.  71. — Sims  Position,  Showing  the  Use  op  One  Sheet  for  Draping. 
The  patient  inclines  slightly  forward  from  the  lateral  position,  has  his 
knees  drawn  upward,  and  if  he  is  under  an  anesthetic  he  will  need  a  sandbag 
against  his  hips  and  chest  to  stabilize  him. 


Fig.  72. — Lithotomy  Position,  Sho^nj.xu  the  Use  of  the  Table  Stirrups. 


278  TEXTBOOK  OF  SURGICAL  NURSING 

Latero-Prone  Position. — This  Avill  be  used  for  operations 
upon  the  chest  (Fig.  69).  The  body  is  turned  about  half  way 
between  the  lateral  and  the  prone  positions,  and  the  chest  and 
hips  rest  against  sandbags,  the  lower  arm  lying  at  the  back 
and  the  other  upward  toward  the  face. 

The  elorsal  elreipiug  is  adaptable  to  this  position. 

Reversed   Trendelenburg. — In   this   position   the   patient  is 


Fig.  7.3. — Draping  avith  a  Sheet  and  Towels  in  the  Lithotomy  Posi- 
tion. The  blunt  towel  clamp  shown  in  Fig.  62  will  be  needed  to  keep  the 
sheet  in  place  at  each  heel  and  to  bind  the  sheet  and  towels  together  about 
the  stirrups. 

placed  upon  the  table  face  downward  with  the  hip  joints  di- 
rectly over  the  line  at  which  the  foot  section  of  the  table  breaks, 
with  the  arms  over  the  head.  Screw  the  table  upw^ard  as  in 
the  Trendelenburg  position,  allowing  the  foot  to  drop  at  the 
same  time  (Fig.  70).  The  patient  will  be  so  well  balanced  in 
this  position  as  a  rule  that  the  shoulder  guards  will  not  be 
needed. 


THE  OPERATING  ROOM  IN  ACTION 


279 


This  position  will  be  used  for  some  operations  upon  the  rectum. 

The  principles  of  the  dorsal  draping  will  apply  here. 

Sims  Position. — This  will  be  used  occasionally  for  examina- 
tions of  the  rectum.  There  is  no  essential  difference  in  the  ar- 
ranr-ement  of  the  patient's  body  between  this  position  and  the 


Fig.  74. — Dkapixg  with  the  Lithotomy  Towel  and  Stockings  for 
THE  Lithotomy  Position.  A  blunt  towel  clamp  will  be  needed  at  either 
edge  of  the  towel  near  the  top  to  keep  it  in  place.  If  this  towel  is  wet 
it  will  stay  in  place  better. 

latero-prone  one,  except  that  the  patient  will  lie  on  the  left 
side. 

As  the  draping  will  rarely  ever  need  to  be  sterile  the  way  in 
which  it  is  done  is  not  important,  but  Fig.  71  will  show  how  it 
may  be  done  with  one  sheet. 

Lithotomy  Position. — ^For  this  position  (Fig.  72)  some  kind 
of  leg  supports  will  be  needed.  Metal  ones  called  stirrups 
(see  illustration)  will  doubtless  be  supplied  with  your  table, 
but  if  not,  one  of  the  devices  which  we  describe  iu  Chapter  XXI, 


280 


TEXTBOOK  OF  SURGICAL  NURSING 


page  412,  under  improvised  positions  for  operations  in  the 
home  may  be  used.  The  stirrups  are  put  into  place,  the  foot 
of  the" table  is  dropped,  the  patient's  feet  being  held  meantime, 
the  i)atient  is  drawn  down  so  that  the  buttocks  project  slightly 
over  the  end  of  tlic  table,  and  the  legs  are  then  fastened  up- 
ward and  backward  so  as  to  throw  the  knees  well  backward 
toward  the  abdomen.  Sometimes  a  sandbag  may  be  placed 
under  the  buttocks  to  adjust  the  position  of  the  pelvic  organs, 


Fig.  75. — Breast  Position.  A  small  sandbag-  will  be  necessary  under 
the  shoulder,  if  the  axilla  is  involved,  to  throw  the  part  away  from  the  table. 
Note  the  wire  arch,  the  Kocher  guard,  which  extends  across  the  table  in  the 
plane  of  the  patient's  shoulders.  A  di'aping  sheet  thrown  across  this  iso- 
lates the  anesthetist  from  the  operative  field.     (See  Fig.  77.) 


or,  for  the  same  reason,  the  foot  of  the  table  may  be  slightly 
elevated  as  in  the  Trendelenburg  position.  A  Kelly  pad  or  a 
rubber  sheet  must  always  be  used  over  the  end  of  the  table.  In 
this  position  the  arms  will  have  to  be  arranged  at  the  chest. 

The  lithotomy  position  will  be  used  for  some  gynecological^ 
gemtourinary  and  rectal  operations. 

The  draping  may  be  done  with  a  sheet  and  towels  (Fig.  73), 
or,  better,  with  the  lithotomy  stockings  and  towel  (Fig.  74) 
described  on  page  231. 

Breast  Position. — For  operations  upon  the  breast  the  patient 
will  lie  upon  her  back.     If  the  disease  is  malignant  the  axillary 


THE  OPERATING  ROOM  IN  ACTION 


281 


Fig.  76. — Method  of  Draping  the  Hand  and  Forearm  for  the  Breast 
Operation.  A  towel  folded  once  crosswise  is  thrown  over  the  hand  and 
is  then  bound  about  the  wrist  with  a  towel  folded  lengthwise  into  a  narrow 
strip  and  applied  like  a  bandage.  The  remainder  of  the  forearm  is  cov- 
ered in  this  fashion,  two  or  more  towels  being  needed  to  make  the  draping 
secure,  and  a  towel  clamp  serving  to  bind  the  end.      (See  Fig.  77.) 


Fig.  77. — Draping  for  Breast  Position. 


282 


TEXTBOOK  OF  SURGICAL  NURSING 


glands  will  be  removed  as  well  as  the  breast,  and  in  this  ease  the 
arm  on  the  affected  side  must  be  free.  Usually  a  small  pillow 
or  sandba<g  will  be  placed  under  the  shoulder  on  this  side  to 
throw  the  axilla  well  up  from  the  table  (Fig.  75).  fhe  unin- 
volved  arm  may  be  placed  either  at  the  side  or  on  the  chest. 

For  a  simple  breast,  operation  the  dorsal  draping  will  apply. 
When  the  axilla  is  involved,  however,  the  draping  is  more  com- 
plex and  may  be  done  as  follows :  After  the  operative  field  has 
been  sterilized  the  patient's  head  and  shoulders  are  liftud,  a 


Fig.    78. — DF.TAciiAin.E   Arm   Eoard   Supplied  with   the   Table. 


rubber  sheet  is  spread  under  the  shoulders  and  over  the  side  of 
the  table  by  an  assistant,  and  a  sterile  sheet  is  then  passed 
under  the  shoulders  so  that  the  table  is  well  covered  in  the  re- 
gion of  the  axilla ;  the  hand  and  forearm,  which  have  been  held 
by  an  unsterile  assistant,  are  then  covered  with  sterile  towels, 
beginning  at  the  hand  with  one  which  is  folded  once  cross- 
wise, making  a  nearly  square  cover  which  is  allowed  to  fall  in 
folds  about  the  wrist,  and  continuing  from  the  w^rist  to  the  oper- 
ative field  with  towels  folded  lengthwise,  bandage  fashion  (Fig. 
76),  Wet  towels  are  better  for  this  purpose  as  they  stay  in 
place  better.     The  general  principles  of  the  dorsal  draping  may 


THE  OPERATING  ROOM  IN  ACTION 


283 


then  be  applied,  the  arm  and  the  axilla  being,  of  course,  a  part 
of  the  operative  field  (Fig.  77). 

There  is  an  attachment  supplied  with  the  more  complete 
tables  which  will  be  very  useful  in  the  breast  case — it  is  the 
Kocher  guard,  and  it  is  simply  a  semicircular  piece  of  soft 
metal  which  is  fitted  vertically  across  the  table  in  about  the 
plane  of  the  patient's  chin  (see  Figs.  75,  76  and  77),  and  serves 
the  purpose  of  holding  the  upper  sterile  sheet  well  up  between 
the  operative  field  and  the  anesthetist.     This  is  a  very  service- 


FiG.  79. — Simple  Long,  Narrow  Board  which  IMay  Be  Fitted  to  Ant 
Table  as  an  Arm  Board. 

able  attachment,  and  if  not  supplied  with  the  table  may  be 
very  easily  improvised.  There  are  other  devices  designed  to 
serve  the  same  purpose  but  the  Kocher  guard  is  adaptable  to 
a  greater  variety  of  positions  as  it  is  made  of  soft  metal  and  can 
be  bent  into  any  desired  shape  (see  adaptation  of  it  for  neck 
cases  in  Fig.  85,  page  289). 

Arm  Position. — Many  hand  and  arm  operations  can  be  done 
with  the  part  simply  laid  upon  the  patient's  body,  but  often  a 
small  table  will  be  needed,  an  arm  board  which  is  supplied  with 
some"  tables  may  be  attached  (Fig,  78),  or  a  simple  long,  narrow 
board  may  be  used  as  illustrated  in  Fig.  79. 

The  laparotomy  sheet  will  serve  well  in  some  cases  for  draping, 


284 


TEXTBOOK  OF  SURGICAL  NURSING 


the  arm  being  simply  slipped  through  the  opening  and  un- 
sterile  parts  of  the  arm  wrapped  with  towels  as  described  for 
the  breast,  case  (Fig.  76),  or  two  sheets  may  be  arranged  as  for 
the  leg  (see  Fig.  80),  any  uninvolved  part  of  the  arm  or  hand 
being  wrapped  with  towels,  as  just  described. 

Leg  Positions. — A  great  variety  of  positions  will  be  em- 
ployed from  time  to  time  for  operations  upon  the  various  parts 
of  the  feet  and  legs,  depending  upon  whether  the  anterior  or 
the  posterior  aspect  or  both  must  be  accessible.     The  simple 


Fig.  80. — Use  of  Stirrups  for  Operations  upon  the  Leg. 


dorsal  position  with  a  sandbag  under  the  heel  will  answer  for 
the  anterior  aspect  of  the  leg  and  for  the  foot  except  when  the 
heel  is  involved,  in  which  case  it  may  be  necessary  to  turn  the 
patient  either  upon  his  side  or  his  face,  and  in  this  latter  posi- 
tion, of  course,  the  posterior  aspects  of  the  legs  are  also  ac- 
cessible. 

Another  plan  which  gives  access  to  all  parts  of  the  feet  and 
legs  is  to  suspend  them  from  the  tahle  stirrups  which  are  used 
for  the  lithotomy  position  (Fig.  80).  This  position  applies 
especially  well  in  the  case  of  operations  for  the  removal  of 
numerous  and  scattered  varicose  veins. 


THE  OPERATING  ROOM  IN  ACTION 


285 


The  draping  for  leg  cases  is  difficult,  but  two  large  sheets  and 
a  few  towels  will  answer  all  needs.  The  parts  are,  of  course, 
first  sterilized  and  the  necessary  sandbags  and  rubber  sheets 
put  into  place,   and  then,  while  a  sterile   assistant  holds  the 


HRBBPB'^HH 

HP 

HHP^ 

1 

^    Ti?^W 

A 

m. 

'  _c^-' 

..  \  A 

'  \ 

V 

Fig.  81. — Draping  for  Leg  Operations.  One  sheet  is  used  under  the 
legs  and  one  thrown  over  the  patient 's  trunk  and  allowed  to  meet  this,  and 
the  two  clamped  together.  Considerable  slack  should  be  allowed  in  the 
lower  sheet  as  otherwise  the  draping  will  be  disarranged  when  the  legs  are 
moved  about  during  the  operation. 


Draping  for  a  Face  Case. 


legs,  a  sterile  sheet  is  passed  underneath  them  over  the  entire 
foot  of  the  table  and  well  upward  to  the  border  of  the  operative 
field;  another  sheet  is  thrown  over  the  patient's  trunk  and  down- 
ward to  meet  the  other  one,  and  the  edges  of  the  two  are  then 
clamped  together  both  between  the  legs  and  on  the  outside  (Fig. 


286 


TEXTBOOK  OF  SURGICAL  NURSING 


81).     Extra  towels  may,  of  course,  be  placed  upon  the  sheet 
underneath  the  parts  if  thought  necessary  for  safety. 

When  the  feet  are  not  included  in  the  operative  field  they 
must  be  well  wrapped  in  towels  after  the  fashion  advised  for 
the  hand  (Fig.  76),  or,  a  very  convenient  plan  is  to  use  a  heavy 
white  cotton  sock  or  stocking  which  can  be  securely  clamped 
at  the  edge  the  same  as  the  towel.  Any  uninvolved  part  of 
the  leg  should  also  be  covered.     When  only  one  leg  is  involved 


J^'iG.  «;i — Arrangement  of  Patient  in  the  Prone  Position  on  a  Spe- 
cial Head  Eest  for  Operations  Upon  the  Back  of  the  Head  or  Neck. 
Some  such  method  is  necessary  when  it  is  essential  to  the  surgeon  that  the 
head  be  not  turned  as  it  would  need  to  be  were  it  lying  upon  the  table. 


the  only  variation  will  be  that  the  other  will  simply  be  covered 
with  the  lower  sheet. 

When  the  stirrups  are  used  they  may  te  sterilized  ly  'boiling 
if  a  sterilizer  large  enough  for  them  is  available,  and  otherwise 
they  may  be  wrapped  in  sterile  towels. 

Head  Positions. — In  practically  all  head  cases  a  small  sand- 
bag will  be  needed  under  the  head,  because  otherwise  it  will  not 
be  stable.  This  will  simply  be  so  adjusted  as  to  make  the  oper- 
ative field  most  accessible. 

For  the  face  and  mouth  (tonsils,  etc.)  and  the  front  and  top 


THE  OPERATING  ROOM  IN  ACTION 


287 


of  the  skull  the  patient's  body  will  be  in  the  'dorsal  position  and 
the  head  turned  as  necessary. 

For  operations  upon  the  face  the  draping  will  be  done  as 
follows:  The  patient's  head  and  shoulders  are  held  up  and  a 
sheet  with  a  wet  towel  laid  upon  it  is  passed  underneath  so 
that  the  sheet  will  extend  well  up  under  the  shoulders  and  the 
towel  will  come  into  position  directly  under  the  head  which  is 


Fig.  84. — Folded  Towel  Clamped  About  the  Face  to  Protect  the 
Operative  Field  from  the  Inhaler  in  Face,  Neck,  or  Skull  Qperations. 


now  laid  upon  the  towel.  This  wet  towel  is  then  wrapped  and 
clamped  securely  around  the  head  and  hair  (Fig.  82),  a  sheet 
is  thrown  over  the  patient's  body  and  clamped  about  the  neck 
to  the  lower  sheet. 

In  all  operations  about  the  head  it  is  advisable  that  the  anes- 
thetist be  supplied  with  a  sterile  ether  mask,  sterile  gloves,  and 
a  sterile  cover  for  his  ether  can,  unless,  of  course,  the  vapor 
method  of  administering  the  anesthetic  is  used,  in  which  case 
the  unsterile  apparatus  may  be  carried  out  of  the  way  by  means 
of  its  rubber  tubing. 

For  the  hack  of  the  head  the  position  just  described  may  an- 
swer, the  simple  prone  position  may  be  used,  or  the  patient  may 


288  TEXTBOOK  OF  SURGICAL  NURSING 

have  to  be  placed  in  the  prone  position  and  some  such  device 
as  is  shown  in  Fig.  83  added  for  the  convenience  of  the  anes- 
thetist. This  last  position,  of  course,  involves  the  special  equip- 
ment of  the  head  rest,  but  a  small  table  or  some  other  article 
of  furniture  may  be  adapted. 

For  all  head  cases  the  arms  should  he  arranged  at  the  pa- 
tient 's  side.  This  is  a  somewhat  strained  position  for  them  when 
the  prone  position  is  used  but  they  will  be  too  much  in  the  way 
over  the  head. 

The  draping  for  an  operation  upon  the  skull  when  the  patient 
lies  upon  his  back  or  in  the  simple  prone  position  will  be  done 
thus:  The  usual  sandbag  and  rubber  sheet  are  first  adjusted, 
the  patient's  head  is  held  from  the  table  and  sterilized,  a  sterile 
sheet  is  passed  well  under  it,  and  the  head  may  then  be  laid 
upon  this,  after  w-hich  the  top  sheet  is  applied  and  a  folded 
towel  clamped  about  the  face  as  shown  in  Fig.  84  to  isolate  the 
anesthetist.  When  the  special  head  rest  is  used  one  sheet  thrown 
over  the  patient  and  clamped  about  the  neck  and  the  folded 
towel  about  the  face  wall  be  about  all  the  draping  necessary. 

One  or  two  metal  face  guards  are  made  specially  for  sepa- 
rating the  operative  field  and  the  inhaler  in  such  cases,  but 
draping  with  them  wall  be  easy  if  one  can  do  it  as  just  de- 
scribed. 

For  nose  and  throat  operations  done  under  local  anesthesia, 
with  the  patient  sitting  in  a  chair,  a  towel  about  the  head  and 
one  sheet  thrown  about  the  patient  and  clamped  together  at  the 
back  of  the  neck  will  usually  suffice. 

Neck  Positions. — The  sandbag  and  the  rubber  sheet  will  al- 
ways be  used  as  for  the  head  cases,  but  the  head  will  usually 
be  thrown  further  back,  particularly  w^hen  the  operation  is  for 
goiter;  and,  of  course,  well  to  one  side  for  cervical  gland  cases. 

As  in  all  operations  about  the  head,  the  problem  of  isolating 
the  anesthetist  is  an  aw^kward  one  to  solve,  but  where  the  Kocher 
guard  is  available  it  may  be  so  bent  and  draped  as  to  make  a 
technically  perfect  arrangement  and  a  reasonably  convenient 
one  for  all  concerned  (Fig.  85).  In  this  case,  after  the  neck  has 
been  sterilized  a  sterile  sheet  is  passed  under  it  and  the  shoul- 
ders; another  sheet  is  then  thrown  over  the  patient's  body  and 


THE  OPERATING  ROOM  IN  ACTION  289 


Fig.  85. — The  Kocher  Guard  Adjusted  and  Draped  so  as  to  Isolate 
THE  Anesthetist  in  Operations  upon  the  Neck. 


290 


TEXTBOOK  OF  SURGICAL  NURSING 


the  edge  passed  about  the  neck  and  clamped  at  the  back,  A 
third  sheet  is  then  thrown  over  the  Koeher  guard  and  clamped 
about  the  .neck  also.  This  latter  clamp  is  best  adjusted  by  an 
unsterile  person  on  the  anesthetist's  side  of  the  guard.  There 
are  other  designs  of  guard  Avhieh  are  very  suitable  for  this  pur- 
pose of  isohiting  the  anesthetist,  but  it  is  not  necessary  to  enu- 
merate them,  for  if  one  can  adjust  the 
Koeher  guard  satisfactorily  the  others 
will  not  be  puzzling. 

When  a  guard  is  not  used  the  pro- 
cedure should  be  in  general  as  de- 
scribed for  face  cases,  including  care- 
ful isolation  of  the  anesthetist. 


When  there  is  a  separate  anesthetiz- 
ing room  the  preparation  and  draping 
are  best  done  there  and  the  table  rolled 
into  the  operating  room  fully  prepared 
for  the  surgeon.  It  will  thus  be  seen 
that  convenience  will  require  that  the 
sterile  preparation  and  draping  sup- 
plies be  stationed  in  the  anesthetizing 
room.  AA^ith  the  drum  system  this 
will  be  easy,  but  otherwise  it  will  be  necessary  to  have  a  sterilly 
draped  table  for  the  purpose ;  or,  if  conditions  do  not  make  this 
possible  or  safe  a  small  stand  (Fig.  86),  which  is  easily  carried 
may  be  prepared  for  each  individual  case  and  carried  into  the 
preparation  room  each  time. 


Fig.  86. — Portable  Dress 
ING  Stand. 


THE  OPERATION 

It  "will  not  be  possible  to  do  more  than  barely  outline  the 
procedure  of  the  nursing  staff  during  an  operation,  because 
there  are  so  many  minor  details  which  will  differentiate  almost 
every  operation  from  every  other. 

In  general,  however,  especially  where  a  number  of  opera- 
tions are  done  in  immediate  succession,  there  should  be  a  rec- 
ognized head  nurse  who  will  be  responsible   for  the  general 


THE  OPERATING  ROOM  TN  ACTION  291 

management  of  the  nurses'  end  of  the  work,  and  for  the  dis- 
pensation of  the  sterile  supplies  as  needed.  As  the  sterile  sup- 
ply drums  or  tables  must  serve  for  all  the  cases  it  is  evident 
that  no  person  but  an  absolutely  sterile  one  can  draw  supplies 
from  them,  and  this  makes  it  obligatory  that  one  nurse,  prefer- 
ably the  head  nurse,  do  nothing  but  serve  as  the  connecting  link 
between  these  supplies  and  those  who  use  them.  This  means 
that  she  never  touches  anything  that  has  been  in  contact  with 
any  case,  because,  of  course,  no  matter  how  "clean"  a  given 
operation  may  be  it  is  not  considered  clean  in  relation  to  any 
other,  and  this  nurse  must  serve  as  the  guardian  of  every  pa- 
tient's right  to  the  benefit  of  every  doubt.  This  may  seem 
like  overdoing  the  matter,  and  if  every  nurse  on  the  staff  were 
highly  experienced  perhaps  it  would  be,  but  it  must  be  remem- 
bered that  the  operating  room,  like  the  wards  and  every  other 
nursing  department  of  the  hospital,  is  a  training  school,  that 
inexperience  is  rampant,  and  that,  therefore,  many  sacrifices 
must  he  made  to  the  cause  of  education,  and  many  otherwise  un- 
necessary precautions  taken  against  the  dangers  of  inexperience. 

We  have  already  pointed  out,  but  it  needs  repetition,  that 
handling  of  sterile  supplies  must  &e  kept  at  the  absolute  mini- 
mum; and  furthermore,  nothing  that  can  be  handled  with  for- 
ceps should  be  touched  with  the  gloves,  for  the  very  good  reason 
that  an  instrument  can  be  made  sterile  and  kept  so  with  much 
greater  certainty  than  a  pair  of  gloves  on  the  two  hands  of  any 
given,  and  very  busy,  human  being. 

The  numler  of  assistant  sterile  nurses  will  be  determined  by 
circumstances,  but  as  a  rule,  in  large  institutions  especially,  one 
or  two  others  may  be  present  to  help  about  the  wound  in  the 
way  of  holding  retractors,  etc.  An  unsterile  nurse  to  do  er- 
rands will  be  useful;  and  this  is  logically  the  lesson  with  which 
a  beginner  should  be  initiated  into  the  mysteries  of  the  operat- 
ing room  in  action. 

One  or  more  orderlies  will  be  necessary  about  an  operating 
room  to  do  the  heavy  lifting  and  other  heavy  work  which  nurses 
cannot  do.  Other  duties  for  orderlies  will  vary  with  local 
conditions. 

Management  hetween  operations  should  be  well  thought  out, 


292  TEXTBOOK  OF  SURGICAL  NURSING 

and  the  ease  and  despatch  Avith  which  the  Avork  of  this  period 
is  done  will  depend  almost  entirely  upon  the  number  of  as- 
sistants. It  may  not  be  possible  for  the  head  nurse  to  remain 
sterile  at  this  time  because  it  is  likely  that  her  staff  will  be  di- 
vided between  the  patient  just  finished  and  the  one  to  follow 
and  she  will,  therefore,  need  to  do  some  of  the  unsterile  work 
between  operations. 

Too  much  haste  must  he  avoided  during  the  period  of  re- 
sterilization  between  operations,  and  special  precautions  must 
be  taken,  of  course,  after  an  infected  case.  Everything  that  has 
been  used  or  subjected  to  contamination  in  any  way  must  be 
rehoiled  or  discarded,  all  soiled  linen  removed,  the  floor  basins 
emptied,  and  the  floor  mopped.  Where  possible  the  patient 
should  have  been  taken  to  another  room  (the  recovery  room), 
or  at  least  a  distant  corner  of  the  operating  room,  before  blankets 
are  applied  or  other  preparations  made  for  the  transference  of 
the  patient  to  his  bed,  as  a  great  deal  of  dust  may  be  raised  in 
this  process  and  other  unsterile  things  scattered  about.  Gown, 
or  apron,  and  gloves  are  of  course  changed,  and  before  the  fresh 
ones  are  put  on  the  hands  should  be  rinsed  in  the  bichloride  or 
other  solution  again,  because  it  is  rarely  possible  that  one  has 
avoided  contact  with  the  soiled  gloves  or  goAvn  in  the  act  of 
their  removal. 

Attention  should  be  called  here  to  an  item  which  is  often 
overlooked,  namely,  that  if  the  operating  table  has  been  sub- 
jected to  contamination  in  an  operation  it  must  not  be  used 
again  till  it  has  been  thoroughly  cleansed.  In  cases  of  known 
infection  it  may  be  protected  in  advance  by  putting  rubber 
sheets  in  strategic  places,  but  contaminating  drainage  cannot 
always  be  foreseen,  and  the  operating  table,  because  of  its  many 
corners  and  crevices,  may  become  through  such  cases  a  very 
active  carrier  of  infection. 

AFTER  THE  OPERATION 

It  will  be  the  practice  to  operate  upon  the  patients  of  any 
given  group  in  such  order  that  the  cleanest  one  is  done  first 
and  the  least  clean  one  last,  and  so,  at  the  end  of  a  session  the 
operating  room  will  be  in  more  need  of  resterilization  than  at 


THE  OPERATING  ROOM  IN  ACTION  293 

any  time  during  the  session.  It  must,  therefore,  have  the  most 
thorough  renovation  at  this  time. 

In  most  hospitals  the  laundry  will  be  equipped  and  the  help 
trained  to  dispose  of  the  soiled  linen  properly,  bu.t  in  any  case 
the  operating  room  nurse  must  see  that  no  linen  which  is  viru- 
lently contaminated  is  carried  about  until  it  has  been  rendered 
innocuous.  Perhaps  the  best  method  of  doing  this  is  to  soak 
the  linen  for  several  hours  in  a  1%  or  2%  solution  of  formalin. 
This  disinfectant  is  a  very  active  one,  and  it  does  not  injure 
the  linen,  but  gloves  should  be  worn  for  wringing  it  from  the 
linen  after  sterilization  for  it  is  highly  irritating  to  the  skin. 

The  floor  must  receive  special  attention,  especially  if  infec- 
tious material  has  been  scattered  about.  In  cases  of  known 
serious  contamination  of  the  floor  it  must  be  flushed  for  a  time 
with  some  antiseptic  solution  before  a  maid  is  asked  to  subject 
her  hands  and  knees  or  the  mop  to  it.  Formalin  will  answer 
well  for  this  purpose,  but  it  should  not  be  forgotten  that  for- 
malin, giving  off  its  pungent  fumes  from  a  large  floor  surface, 
will  quickly  make  a  room  uninhabitable  if  the  doors  and  win- 
dows have  not  been  previously  opened. 

Walls  'and  all  furniture,  including  the  operating  table,  which 
may  have  been  subjected  to  blood  stains  or  other  contamination, 
must  be  well  washed ;  and  of  course  the  dressing  and  anesthet- 
izing rooms  will  be  thorouglily  renovated. 

The  instruments  are  washed  in  warm  water  and  soap,  hot 
water  being  avoided  as  it  will  coagulate  any  blood  present  and 
make  it  very  difficult  to  dislodge.  For  the  same  reason  clamps 
and  other  jointed  instruments  must  be  taken  apart  for  the 
washing  so  as  to  insure  thorough  cleansing  before  boiling.  They 
should  then  be  boiled  for  10  or  15  minutes.  After  they  are 
boiled  about  all  they  will  need  to  put  them  into  good  condition 
will  be  thorough  drying,  each  one  being  taken  apart  as  much  as 
possible  for  this.  If  they  are  wiped  directly  from  a  hot  water 
bath  the  heat  which  they  retain  will  appreciably  aid  in  com- 
pletely freeing  inaccessible  parts  from  moisture  and  thus  pre- 
vent rust.  Rusted  parts  should  be  scoured  gently  with  a  fine 
polish,  such  as  ''bon  ami,"  but  scouring  should  be  done  spar- 
ingly for,  while  it  may  give  an  instrument  case  a  brighter  ap- 


294  TEXTBOOK  OF  SURGICAL  NURSING 

pearance,  it  materially  shortens  the  span  of  life  of  the  nickel 
plating.  Delicately-jointed  instruments  should  be  oiled  imme- 
diately, and  all  should  be  provided  -with  a  dry  storage  place. 

The  gloves  are  well  scrubbed  on  both  sides  with  soap  and 
warm  water,  hot  Avater  being  precluded  for  the  same  reason  as 
for  the  instruments.  It  is  even  more  important  that  blood 
should  be  thoroughh'  removed  from  gloves  as  the  sterilization 
will  render  absolutely  irremovable  any  that  may  have  been  left 
upon  them.  Before  further  handling  they  should  then  be 
boiled  for  about  5  minutes,  not  being  put  into  the  water,  of 
course,  till  it  has  reached  the  boiling  point ;  and  then  they  are 
dried  and  tested  for  holes.  The  test  for  defects  is  an  important 
one,  and  a  great  deal  of  practice  will  be  necessary  to  learn  to 
do  it  without  oversights.  It  must  be  remembered  that  the 
smallest  pinhole  may  allow  the  passage  of  infection  to  the 
wound  from  the  hand,  and  that  all  tests  must  be  made  with 
these  in  mind.  A  good  method  is  to  hold  the  cuff  open,  the 
fingers  of  the  glove  being  downward,  in  which  position  they 
will  be  well  inflated  with  air;  then  quickly  grasp  the  edges  of 
the  cuff  together,  confining  the  air  which,  under  a  little  pres- 
sure, can  be  felt  by  the  cheek,  for  instance,  escaping  from  the 
smallest  perforation.  If  the  glove  is  in  good  condition  gener- 
ally, the  holes  should  be  patched,  as  nurses  and  junior  staff  as- 
sistants can  wear  patched  gloves  without  inconvenience.  Too 
great  economy  must  not  be  exercised,  however,  in  the  salvaging 
of  torn  gloves  because  when  a  glove  becomes  so  old  and  life- 
less that  it  tears  easily  it  is  a  menace  and  should  be  thrown 
away.  Cuffs  and  other  strong  parts  of  badly  torn  gloves  can 
be  utilized  for  the  patches  which  should  not  be  cut  any  larger 
than  is  necessary  to  make  a  durable  repair. 

Patching  is  something  of  an  art,  too,  but  if  done  skillfully 
a  patch  will  usually  outlast  the  remainder  of  the  glove.  It  is 
done  thus:  Turn  the  glove  wrong  side  out — this  is  important 
because  the  wrong  side  of  the  rubber  is  usually  rougher  than 
the  right  side  and  the  cement  will  therefore  adhere  better; 
locate  the  hole  accurately;  cut  a  patch  to  fit;  sponge  both  the 
patch  and  the  region  of  the  hole  rather  vigorously  with  benzine 
— this  will  cleanse  the  surfaces  and  at  the  same  time  somewhat 


THE  OPERATING  ROOM  IN  ACTION  295 

roughen  them ;  apply  a  thin  coat  of  rubber  cement  to  the  patch, 
quickly  put  the  patch  into  place,  and  press  firmly  for  a  few 
moments  until  the  cement  has  dried  well.  Note  that  the  ce- 
ment is  better  applied  to  the  patch  than  to  the  glove,  because 
it  will  not  be  possible  to  estimate  the  exact  space  required  on  the 
glove.  A  light  sponging  with  benzine  over  the  region  will  com- 
plete the  process  neatly.  Do  not  sterilize  these  gloves  until  the 
cement  has  had  several  hours  in  which  to  dry  completely. 

All  unused  sterile  supplies  which  have  been  opened  must 
be  resterilized,  including  all  drums.  This  may  seem  like  an- 
other case  of  overprecaution,  when  little  has  been  used  from 
a  parcel,  but  if  this  were  not  made  the  rule  such  a  parcel 
might  remain  in  reserve  too  long;  for  it  ought  to  be  the  prac- 
tice to  resterilize  all  supplies  at  least  as  often  as  once  a  week. 
For  this  reason  it  is  not  good  technic  to  keep  more  than  one 
week's  stock  sterilized  ahead,  and  some  system  ought  to  be  in 
operation  whereby  the  parcel  longest  in  reserve  should  always 
be  used  first.  In  a  large  establishment  where  it  is  hard  to  fol- 
low every  detail  regularly,  it  is  wise  to  mark  each  parcel  with 
the  date  of  sterilization  so  that  too  old  ones  may  be  detected. 

All  the  miscellaneous  utensils  used  must,  of  course,  be  re- 
sterilized  before  they  are  stored  away, 

CONCLUDING  SUGGESTIONS 

Aim  to  have  only  standard  equipment,  and  no  more  of  that 
than  you  use. 

Try  to  keep  your  methods  and  your  entire  system  as  simple 
as  possible.  The  natural  tendency  of  operating  room  technic 
is  to  become  complex  and  involved  and  constant  good  manage- 
ment is  required  to  prevent  nonessentials  from  superseding 
and  supplanting  essentials. 

Do  not  overstock  in  sterile  supplies,  and  keep  what  you  have 
in  circulation. 

If  your  operating  room  is  a  training  ground  for  pupil  nurses 
do  not  forget  the  educational  phase  of  the  work  in  the  press  of 
routine  requirements.  The  two  can  prosper  hand  in  hand  but 
all  concerned  must  recognize  them  both  and  someone  must  study 
the  system  and  guide  it  wisely. 


CHAPTER  XVII 

INSTRUMENT  PASSING 

As  a  rule  there  will  not  be  time  enough  during  the  routine 
course  of  training  in  the  operating  room  for  the  nurse  to  gain 
an  intimate  knowledge  of  the  uses  of  instruments  and  suture 
materials,  but  as  she  will  very  often  be  called  upon  after  grad- 
uation to  assume  the  responsibility  for  providing  the  .proper 
ohes  and  for  officiating  at  the  operating  table  as  "instrument 
passer,"  we  shall  record  here  a  few  principles  which  should 
guide  her  in  this  duty,  and  as  many  details  as  it  will  seem 
worth  while  for  her  to  learn  in  the  abstract. 

The  subject  is  a  very  difficult  one  to  present  on  paper  in  any 
other  than  a  general  way  because  in  practice  there  will  re- 
peatedly arise,  through  preferences  of  surgeons  and  the  di- 
versities and  irregularities  of  cases,  variations  in  detail  of  both 
instruments  and  technic  which  cannot  possibly  be  foreseen. 
Moreover,  we  have  not  the  space  here  to  cover,  even  in  a  gen- 
eral way,  every  one  of  the  hundreds  of  operations  that  may 
be  performed  upon  the  human  body;  but  we  advise  every 
prospective  instrument  passer  who  wishes  to  work  intelligently 
and  resourcefully  to  secure  access  to  one  of  the  good  hooks 
which  surgeons  have  written  on  operative  surgery  and  familiar- 
ize herself,  with  the  probabilities,  at  least,  in  any  given  case, 
and  thus  endeavor  to  make  of  herself  an  intelligent  and  co- 
operative assistant  rather  than  a  mere  mechanical  adjunct 
which  she  Avill  otherwise  be,  at  least  until  she  has  had  the  op- 
portunities of  a  long  period  of  observation. 

However,  though  by  actual  count  the  number  of  recognized 
surgical  operations  would  run  well  up  into  the  hundreds,  the 
instrument  nurse  will  find  in  her  study  of  them  that,  after  all, 
from  her  standpoint  they  differ  in  relatively  few  important  re- 
spects.    Her  chief  problem,  therefore,  will  be  to   master  her 

296 


INSTRUMENT  PASSING  297 

general  equipment  and  to  establish  her  technic  as  the  founda- 
tion upon  which  she  can  then  build  very  easily  her  superstruc- 
ture of  detail. 

Accordingly,  we  shall  take  as  the  nucleus  of  our  lesson  a 
representative  operation  which  we  shall  study  in  detail  as  in- 
strument passers,  and  when  we  have  finished  that  and  learned 
it  well  we  can,  with  comparative  ease,  proceed  to  the  necessary 
variations  for  other  cases.  In  doing  this  we  shall  assume  that 
the  nurse  has  been  taught,  in  her  regular  course  of  operating 
room  training  (as  she  should  have  been),  to  recognize  all  of 
the  more  common  instruments,  needles  and  suture  materials. 

Let  us  assume,  then,  that  you  are  to  be  "instrument  passer" 
for  an  appendicectomy.     The  instruments  you  will  provide  are : 

4  towel  clamps 

1  scalpel 

4  pairs  plain  anatomical  forceps  (1  very  fine-pointed) 

2  pairs  toothed  anatomical  forceps 

3  pairs  scissors  (1  straight,  2  curved) 

1  dozen  artery  forceps 
^  dozen  Kocher  clamps 

2  pairs  blunt  retractors  (2  sizes) 

1  pair  "crushing"  forceps   (if  one  of  the  various  special  designs  is 

not  available,  a  strong,  straight  pair  of  hemostatic  forceps  may 
answer) 

3  pairs  sponge  forceps 

2  small  aneurism  needles 
1  probe 

1  grooved  director 

2  needle  holders 

1  pair  dressing  forceps 

2  straight  "round"  needles  (intestinal) 
2  curved  "round"  needles  (intestinal) 

2  curved  "round"  needles    (heavy)  •  ' 

4  curved  "surgeon's"  needles  (2  sizes) 

2  straight  "skin"  needles   (except  where  skin  "clips"  are  used) 

The  suture  material  will  be: 

Plain  catgut,  Nos.  0,  1  and  2 

Chromic  eatg-ut,  Nos.  0  and  2 

Linen  thread  (or  celluloid  linen — ^Pagensteeher) 

Silkworm  gut 


298  TEXTBOOK  OF  SURGICAL  NURSING 

Silk  thread,  horsehair,  or  skin  ''clii)s"  and  the  special  forceps  for  ap- 
plying them 

Everythiug-  being  sterile  and  conveniently  placed,  you  may 
now  arrange  the  instrument  stand  (Fig.  24,  page  199)  in  some 
such  orderl}'  waj^  as  that  suggested  in  Fig.  87,  laying  aside  the 
pair  of  straight  scissors  and  one  pair  of  the  plain  anatomical 
forceps  for  your  own  use  in  handling  the  sutures. 

Next  it  will  be  wise  to  make  a  "suture  look"  from  a  towel 
folded  as  shown  for  the  needle  book  in  Fig.  54,  page  253,  namely, 
by  these  steps:  (1)  Lengthwise,  bringing  each  edge  to  the  mid- 
dle j  (2)  Crosswise,  bringing  each  end  to  the  middle;  (3)  Cross- 
wise, through  the  middle  again,  bringing  the  ends  together; 
(4)  Crosswise,  through  the  middle  again.  This  will  give  you, 
as  shown  in  the  illustration,  a  compact,  book-like  arrange- 
ment of  the  towel  in  which  you  have  two  separate  compart- 
ments in  which  to  store  your  sutures  and  needles  conveniently. 
This  is,  of  course,  not  a  necessity  but  one  of  those  conveniences 
which  will  never  be  discarded  when  once  tested  out,  for  if 
one  assigns  a  place  to  each  kind  of  suture  material  a  great  deal 
of  time  and  trouble  wdll  be  saved  in  finding  what  one  w^ants 
when  pressed  for  time. 

Now,  arrange  in  this  hook  the  suture  material  and  accom- 
panying needles.  You  will  probably  first  be  asked  for  a  liga- 
ture for  the  vessels  about  the  base  of  the  appendix.  This  will 
be  the  No.  1  or  2  plain  catgut  in  the  aneurism  needle,  or  one 
of  the  heavy  round  needles  in  the  needle  holder,  and  you  may 
need  several  of  them.  Next  will  be  the  linen  suture,  the  ' '  purse 
string,"  for  the  appendix,  on  a  straight  intestinal  needle.  The 
next  will  be  the  second  purse  string — the  No.  0  plain  or  chromic 
catgut,  also  on  a  straight  intestinal  needle.  Next  wdll  prob- 
ably be  the  ligatures,  which  should  be  of  No.  1  plain  catgut — 
these  you  can  lay  out  straight  within  one  of  the  folds  of  the 
suture  book  with  the  ends  projecting  so  that  you  can  easily 
grasp  them.  Then  you  will  probably  be  asked  for  the  sutures 
for  closing  the  wound,  Avhich  will  come  in  the  following  order: 
No.  1  plain  catgut  on  either  a  surgeon's  needle,  or  the  heavier 
curved  round  one,  for  the  peritoneum;  No.  2  plain  catgut  for 


INSTRUMENT  PASSING 


299 


«^ 

^ 

2; 

h 

CO 

300  TEXTBOOK  OF  SURGICAL  NURSING 

the  muscle;  the  same,  or  the  No.  2  chromic  for  the  fascia;  next 
you  may  need  the  No.  2  plain  catgut  for  the  fat  layer,  or  per- 
haps some  fine  silkworm  gut  on  a  larger  sharp  needle  for  the 
fat  and  skin  layers  together;  then  will  follow  the  skin  suture 
— the  silk  or  horsehair — on  a  sharp  straight  needle,  or  perhaps 
the  skin  clips.  The  suture  material  is  now  in  convenient  order 
and  you  are  ready  for  the  operation  to  begin. 

The  first  instrument  used  will  be  the  knife,  W'hich  you  will 
have  within  easy  reach,  as  j^ou  will  also  have  the  forceps,  scis- 
sors, clamps,  etc.,  w^hich  will  be  used  next.  You  will  watch 
all  steps  of  the  operation  closely,  replacing  artery  clamps  on 
the  stand  as  they  are  used,  and  endeavoring  to  keep  one  step 
ahead  of  the  surgeon  in  your  preparation.  When  the  appen- 
dix has  been  drawn  up  into  the  wound  you  will  have  the 
aneurism  needle,  or  the  heavy  round  needle  threaded  with  the 
mesoappendix  ligature  ready  to  hand  to  the  surgeon,  and  keep 
yourself  in  readiness  to  hand  him  another  until  this  part  of 
the  operation  is  finished.  Then  will  come  the  linen  purse  string 
on  the  straight  and  fine  round  needle.  At  this  point  you  will 
probably  be  asked  for  the  "crushing"  clamp.  The  appendix 
will  then  be  cut  away  and  the  stump  sterilized,  probably  with 
the  cautery.  Then  the  fine-pointed  pair  of  thumb  forceps  will 
be  used  for  inverting  the  appendix  stump. 

At  this  point  the  instrument  nurse  must  learn  a  special  lesson 
in  technic:  The  appendix  stump  exposes  the  interior  of  the 
intestine  which,  of  course,  is  not  sterile,  and  although  it  has 
been  cauterized,  the  crushing  forceps,  the  inversion  forceps, 
and  the  knife  or  scissors  which  were  used  for  cutting  it  away 
are  not  considered  clean,  and  it  is  the  instrument  nurse's  duty 
to  see  that  these  instruments  are  discarded — a  small  basin  or 
a  folded  towel  may  be  used  to  receive  both  these  and  the  ap- 
pendix and  immediately  handed  to  an  unsterile  attendant.  This 
lesson  should  be  w^ell  learned  and  the  technic  of  carrying  it  out 
well  planned  because  it  will  apply  in  most  operations  where 
a  part  is  removed,  and  in  others  where  an  unclean  step  in- 
tervenes. 

After  the  appendix  stump  has  been  inverted  the  second  purse 


INSTRUMENT  PASSING  301 

string  suture — the  No.  0  plain  or  chromic;  catgut  on  the  straight 
round  needle — will  be  used. 

Then  you  will  provide  the  wound-closing  sutures  in  this  or- 
der: No.  1  plain  catgut  on  a  surgeon's  or  the  heavy  round 
needle  in  the  needle  holder  for  the  peritoneum;  the  No.  2  plain 
catgut  similarly  for  the  muscle ;  the  No.  2  plain  or  chromic  cat- 
gut on  a  surgeon's  needle  for  the  fascia;  the  No.  2  plain  catgut 
on  the  same  needle  for  the  fat  layer,  or  the  silkworm  gut  on  a 
larger  surgeon's  needle  for  the  fat  layer  and  the  skin  com- 
bined; the  silk  or  horsehair  on  the  straight  sharp  needle  for 
the  skin,  or  the  clips  and  their  special  forceps. 

In  some  cases,  usually  where  there  is  infection,  the  wound  will 
be  closed  by  means  of  " through-and-through"  sutures,  that  is, 
the  entire  abdominal  wall  will  be  treated  as  one  layer  and  heavy 
sutures,  such  as  silkworm  gut,  will  be  used  on  large,  strong, 
sharp  needles. 

All  through  the  operation  you  have  endeavored  to  see  one 
step  ahead  and  to  have  ready  in  advance  whatever  will  be 
needed  so  as  to  save  confusion  and  waiting.  This  you  can  only 
do  by  watching  the  operation  very  closely.  Meantime,  you  have 
kept  your  instrument  table  clean  and  in  order,  with  wipes, 
clamps,  etc.,  always  within  easy  reach  of  the  surgeon,  and  un- 
needed  instruments  out  of  the  way. 

You  have  now  passed  instruments  for  an  operation  which  in- 
volves many  of  the  fundamental  principles  of  your  art.  You 
will  need  all  the  types  of  instruments  (except  the  appendix 
crusher)  for  practically  every  operation,  with  special  additional 
ones  which  we  shall  point  out  later ;  the  arrangement  of  the  in- 
strument table  and  the  supply  of  suture  materials  are  standard ; 
and  your  general  course  of  procedure  will  apply  always.  We 
can  then  proceed  to  supplement  this  wdth  the  special  instructions 
for  particular  operations,  but  it  must  be  remembered  that  this 
is  a  subject  on  which  w^e  can  speak  only  in  generalities  and 
probabilities  and  that  you  will  have  to  learn  your  particulars  in 
actual  practice  from  day  to  day  from  your  surgeon  and  from 
your  ever-varying  cases. 

Before  taking  up  the  discussion  of  individual  operations, 
however,  let  us  repeat  that  the  general  set  of  instruments  which 


302  TEXTBOOK  OF  SURGICAL  NURSING 

you  provided  for  tlie  appendix  operation  Mill  be  assumed 
for  all  otiiers,  and  lliat  the  sets  mentioned  under  the  following 
individual  headings  will  merelj^  be  additions.  The  suture  mate- 
rial supply,  on  the  other  hand,  -was  perhaps  as  complex  and 
elaborate  as  it  "will  be  in  any  other  case,  and  mucli  more  so  than 
in  most  of  tliem.  Ligatures,  however,  a])i)ly  universally,  and 
they  will  be  assumed  in  addition  to  the  suture  material  w^e  shall 
mention. 

It  will  also  be  taken  for  granted  that  the  nurse  is  familiar 
Avitli  the  special  designs  of  instruments  suitable  for  different 
structures  and  parts  of  the  body  and  wdll  know  the  difference, 
for  instance,  between  the  "bone-cutting  forceps"  meant  in  the 
list  for  skull  operations  and  the  one  meant  for  operations  upon 
the  extremities.  The  easiest  road  to  this  specific  knowledge  will 
be  a  few  hours  devoted  to  the  study  of  some  complete  illustrated 
instrument  catalog.  This  may  seem  like  learning  the  English 
language  by  studying  the  International  Dictionary,  but  a  trial 
of  the  suggestion  will  prove  its  worth. 

REPRESENTATIVE  OPERATIONS 

We  shall  aim  to  discuss  one  or  more  operations  from  each 
anatomical  group,  and  as  we  shall  select  the  more  complex  ones 
the  nurse  will  have  no  difficulty  in  deducting  from  them  what- 
ever help  she  may  need  for  the  other  simpler  ones  of  the  group 
which  "\ve  do  not  mention. 

In  Chapters  IV  to  XI  operations  have  teen  presented  in  essen- 
tial details  and  in  the  same  anatomical  order  which  will  be  fol- 
lowed here,  and  since  many  special  instruments  have  teen 
pointed  out  there  the  student  should  study  the  corresponding 
subject  in  those  chapters  at  the  same  time  that  she  takes  them 
up  here. 

Intestines. — For  operations  upon  the  intestines  these  special 
instruments  should  be  provided :  2  pairs  of  intestinal  clamps 
with  rubber  tubing  covers  for  the  blades  (A  and  B  or  C  of 
Fig.  88),  large  abdominal  retractors,  6  pairs  of  fine  tenacula 
(Allis's,  for  example),  1  or  2  extra  pairs  of  scissors  and  thumb 
forceps,  and  sometimes  a  Murphy  button. 


INSTRUMENT  PASSING 


303 


The  suture  material  will  usually  be  linen  thread  or  the  Pagen- 
stecher,  and  No.  00  or  0  chromic  catgut ;  and  the  needle  will  be 
the  fine,  straight,  round  intestinal  one  usually,  though  occa- 
sionally a  curved  one  will  be  called  for  instead. 

When  the  interior  of  the  intestine  is  exposed  during  the  opera- 
tion the  instrument  nurse  must  apply  the  special  technic 
described  in  the  case  of  the  removal  of  the  appendix  (page  300), 


Fig.  88. — Intestinal  and  Stomach  Clamps.  A,  plain,  flexible  intes- 
tinal clamp;  B,  the  same  clamp  with  the  rubber  tubing  covers  which  must 
always  be  used  and  which  should  be  slightly  smaller  in  diameter  than  the 
clamp  so  that  they  will  fit  snugly;  C,  larger  double  intestinal  or  stomach, 
clamp  with  the  rubber  tubes  in  place. 


As  in  the  case  of  the  appendix,  a  special  towel  or  basin  should 
be  provided  for  the  reception  of  all  the  instruments  used  during 
the  unclean  stage  of  the  operation,  and  the  instrument  passer 
can  then  manage  to  avoid  contaminating  either  her  own  gloves 
or  her  instrument  table — the  special  forceps  and  scissors  advised 
above  were  for  use  at  this  stage  so  as  to  avoid  the  trouble  o'f 
resterilization  for  the  remainder  of  the  operation. 

When  the  Murphy  button  is  used  the  two  sections  should  be 
screwed  apart  and  each  clamped  in  an  artery  clamp  for  conven- 
ience in  handling.     Purse  strings  of  heavy  linen  or  silk  thread 


304  TEXTBOOK  OF  SURGICAL  NURSING 

on  an  intestinal  needle  will  be  used  for  fastening  them  in 
place. 

The  closure  of  the  ahdominol  ivall  -will  correspond  to  that  of 
the  appendix  Avound. 

Hernia. — There  are  no  special  instruments  required  for  any 
of  the  operations  for  the  repair  of  a  hernia,  except  in  those 
cases  which  involve  strangulation  of  the  intestine.  Then,  of 
course,  you  will  need  to  provide  for  an  operation  upon  the  intes- 
tines as  described  above. 

The  sutures  for  hernia  repair  will  be  in  general  as  follows: 
No.  1  or  2  plain  catgut  on  the  heavier  round  needle  for  the 
''sac";  No.  2  chromic  catgut,  kangaroo  tendon,  or  sometimes 
silkworm  gut  on  the  same  needle  for  the  muscle ;  the  chromic  or 
No.  2  plain  catgut  for  the  fascia;  and  for  the  fat  and  skin  the 
same  as  for  the  appendix  case. 

Gall  Bladder. — The  two  more  common  operations  involving 
the  gall  bladder  are  the  excision  of  the  part  and  the  removal  of 
stones  from  it.  The  instrument  passer  should  always  provide 
for  both,  and  the  only  special  instruments  will  be :  gallstone 
forceps,  gallstone  scoops,  bile  duct  probe,  and  perhaps  a  small 
trocar  with  rubber  tube  attached. 

If  the  gall  bladder  is  removed  a  strong  ligature  of  No.  2  plain 
or  chromic  catgut  on  the  heavier  round  needle  should  be  prepared. 
When  it  is  not  removed  you  may  need  to  supply  a  medium- 
sized  rubber  drainage  tube,  an  ordinary  rubber  catheter  some- 
times being  used;  and  for  closing  the  gall  bladder  around  this 
you  may  need  a  No.  1  chromic  suture  on  a  small  round  needle. 

There  may  sometimes  be  an  anastomosis  performed  between 
the  intestine  and  the  gall  bladder  or  gall  duct.  In  this  case  the 
preparation  described  for  intestinal  operations  Avill  apply  in 
general. 

There  will  probably  be  no  new  feature  about  the  closure  of 
the  wound. 

Tonsils  and  Adenoids. — For  the  removal  of  tonsils  there  are 
many  methods,  but  you  will  always  provide  a  mouth  gag,  a 
tongue  depressor,  a  tonsil-seizing  forceps,  an  eneucleator  or 
dissector,  a  tonsil  punch,  a  pair  of  long  scissors,  and  either  a 
snare  or  one  of  the  many  designs  of  tonsillotomes. 


INSTRUMENT  PASSING  305 

Removal  of  adenoids  usually  accompanies  the  tonsillectomy, 
and  for  this  you  will  simply  need  some  kind  of  adenoid  curette. 

Rectum. — For  excision  of  the  rectum,  if  done  through  an 
abdominal  incision,  the  preparation  for  intestinal  work  will,  of 
course,  apply.  Sometimes,  however,  the  operation  may  be  done 
through  an  incision  hy  ivay  of  the  sacrum,  which  means  that 
you  will  need  a  supply  of  bone  instruments  also.  As  this  opera- 
tion is  rare,  and  to  save  space  here,  we  refer  you  to  page  307, 
under  "Bones,"  for  the  list  of  bone  instruments. 

For  dilatation  of  a  stricture  of  the  rectum  there  are  various 
metal  dilators,  and  bougies  of  several  materials  including  metal, 
hard  rubber,  soft  rubber,  etc. 

Removal  of  hemorrhoids  is  usually  done  by  the  clamp  and 
cautery  method.  For  this  you  will  need  a  rectal  speculum,  a 
pile-seizing  forceps,  a  pile  clamp,  and  the  cautery.  Ordinarily 
you  will  not  need  to  provide  a  rectal  dilator  for  a  hemorrhoids 
operation. 

Where  a  suturing  operation  is  done  No.  2  plain  or  chromic 
catgut  on  a  round  needle  should  be  provided ;  and  for  a  ligation 
operation  strong  silk  will  probably  be  used. 

Stomach. — For  operations  upon  the  stomach,  such  as  a  gastro- 
enterostomy or  removal  of  a  part  of  the  organ,  the  intestinal 
preparation  and  technic  will  apply,  except  that  the  larger  special 
stomach  clamps  will  be  needed  instead  of  the  smaller  intestinal 
ones.    One  variety  of  stomach  clamp  is  shown  in  C  of  Fig.  88. 

Blood  Vessels. — Suturing  of  blood  vessels  will  not  often 
trouble  the  general  instrument  passer,  but  the  material  used 
is  usually  extremely  fine  silk  on  an  extremely  slender  round  nee- 
dle. Special  very  fine  clamps  and  forceps  are  designed  for  this 
purpose  also. 

For  the  removal  of  varicose  veins  one  of  several  designs  of 
special  "strippers"  may  be  used,  though  often  nothing  but  the 
usual  dissecting  instruments  will  be  needed. 

Lymph  Glands. — About  the  only  special  instrument  for  this 
operation  will  be  a  pair  of  suitable  grasping  forceps — a  tenacu- 
lum. Plenty  of  artery  clamps  and  ligatures  will  be  a  wise  pre- 
caution in  these  cases.     Plain  catgut  No.  1  or  2  for  suturing 


306  TEXTBOOK  OF  SURGICAL  NURSING 

the  deeper  stnu'tiires,  and  horsehair  or  silk  for  the  skin  will  be 
the  likely  suture  mufcrial. 

Spleen^ — Operations  iipon  the  spleen  will  be  infrequent. 
Fur  removal  of  the  organ  your  chief  concern  Avill  be  to  provide 
plenty  of  large  hemostatic  forceps  and  strong  ligatures. 
Suturijifj  of  the  spleen  will  probably  be  done  with  plain  catgut 
on  a  round  needle. 

Thyroid  Gland. —  For  the  removal  of  the  gland  the  special 
thyroid  grasping  forceps  or  a  suitable  tenaculum  will  be  the 
only  special  preparation,  aside  from  plenty  of  artery  clamps  and 
ligatures.  Plain  catgut  No,  1  or  2  for  the  deeper  structures  and 
horsehair  or  silk  for  the  skin  will  be  the  likely  suture  meiterial. 

Tendons. — Your  only  special  concern  will  be  in  cases  of 
suture  of  the  tendon,  when  you  will  probably  need  chromic  cat- 
gut or  silk  sutures  on  a  round  needle. 

Brain. — Naturally,  the  special  instruments  needed  for  reach- 
ing the  brain  will  belong  to  the  "bone  instrument"  group,  and 
they  will  be  these: 

Periosteal  elevator  Bone-ciitting  forceps 

Bone  drill,  or  trepbine  Bone-gouging  forceps 

Chisels  Bone  curettes 

Gouges  Small  sharp  retractors    (toothed) 

Mallet  Special  brain  retractors 

When  the  dura  is  to  he  sutured  fine  catgut  on  a  small  round 
needle  will*  probably  be  used.  The  scalp  will  usually  be  closed 
with  silkworm  gut  on  a  surgeon's  needle. 

Nerves. — For  the  suture  of  nerves  fine  chromic  catgut  or 
silk  should  be  provided  on  a  fine  round  needle. 

Spine. — For  operations  upon  the  spine,  which  Avill  be  as- 
sumed to  include  the  spinal  cord,  you  should  provide  the  special 
bone-cutting  forceps  designed  for  the  purpose,  and  in  addition 
to  that,  chisels,  gouges,  mallet,  periosteal  elevator,  exsection  saw, 
and  a  small  blunt  hook. 

,  For  closing  the  ivound  you  will  need  fine  catgut  on  a  round 
needle  for  the  dura,  No.  2  plain  catgut  for  the  deep  structures, 
and  perhaps  silkworm  gut  for  the  skin. 

Bones. — For  all  bone  work,  such  as  the  open  repair  of  frac- 


INSTRUMENT  PASSING  307 

tures,  the  removal  of  the  whole  or  parts  of  bones,  etc.,  you  should 
be  equipped  with  general  hone  instruments  as  follows: 

Periosteal  elevators  Bone  curettes 

Chisels  Bone-holding  forceps  (serinestrnin 

Gouges  forceps) 

Mallet  Saws   (Gigli's,  and  other  suitable 

Bone-cutting  forceps  ones) 

Bone-gouging  forceps  Bone  drill 

In  the  case  of  fracture  the  silver  or  aluminum-bronze  wire 
may  be  used  for  suturing  the  tone  fragments ;  sometimes,  as  in 
the  case  of  the  patella,  chromic  catgut  may  be  needed ;  or,  you 
may  need  to  provide  bone  plates,  such  as  the  "Lane"  plates 
(Fig.  14,  page  101),  and  then  you  will  also  need  screws,  screw 
driver,  and  screw-holding  forceps. 

When  the  "Lane"  plating  is  done  you  may  be  expected  to 
carry  out  the  special  Lane  technic  for  the  operation,  which  means 
a  method  by  which  the  hands  are  never  put  into  the  wound, 
everything  being  done  with  instruments,  and  all  supplies  han- 
dled entirely  with  forceps.  Considerable  practice  will  be  neces- 
sary before  one  can  carry  out  this  technic  well  and  without  great 
fatigue  from  the  close  application  it  will  require.  Its  principle 
is  so  excellent,  however,  that  you  will  do  well  to  acquire  the 
habit  of  applying  it  as  far  as  you  can  in  all  your  instrument  and 
suture  work,  and  with  practice  you  will  find  that  many  of  the 
things  you  usually  fumbled  with  your  fingers — needles,  for 
example — can  be  handled  much  more  easily  and  quickly  with 
forceps. 

For  the  closure  of  fracture  wounds  No.  2  plain  catgut  and 
silkworm  gut  will  be  your  likely  suture  material. 

Reproductive  Organs. — For  the  various  operations  upon  the 
pelvic  organs  through  an  ahdominal  incision  you  should  provide 
these  special  instruments :  Deep  abdominal  retractors,  2  large 
aneurism  needles,  plenty  of  large  hemostatic  (hysterectomy) 
forceps,  sponge  forceps,  one  or  two  tenacula  or  "elevating" 
forceps. 

In  the  case  of  hysterectomy  you  will  need  ligatures  of  No.  3 
or  4  plain  catgut  on  the  aneurism  needle,  or  on  the  heavy  round 


308  TEXTBOOK  OF  SURGICAL  NURSING 

needle  in  the  needle  holder.  These  lip,'atures  should  be  lono; — 
the  full  suture  length — as  it  "will  not  be  convenient  to  tie 
shorter  ones  in  tlie  depths  of  the  pelvic  cavity.  After  the  uterus 
is  removed  you  will  need  the  No.  3  or  4  plain  catgut  and  some- 
times also  the  No.  2  on  a  heavy  shav]i  needle  for  sewing  over 
the  stump. 

Salpingectomy  and  oophorectomy  will  require  no  further 
preparation. 

In  the  case  of  removal  of  a  large  ovarian  cyst  you  should  pro- 
vide a  large  trocar  with  a  long  rubber  tube  attached. 

For  suspension  of  the  uterus  there  are  a  number  of  possibili- 
ties in  the  way  of  sutures,-  but  you  will  probably  guess  well  if 
you  provide  plenty  of  No.  2  chromic  catgut  on  a  medium-sized 
surgeon's  needle. 

Occasionall}'  some  of  these  operations  may  be  done  through  a 
vaginal  incision  instead  of  the  abdominal  one.  This  will  not 
modify  your  preparation  materially  except  that  you  will  need 
vaginal  retractors  instead  of  abdominal  ones. 

For  a  curettage  these  instruments  will  be  needed :  Vaginal 
speculum,  tenaculum,  cervical  dilator,  several  sizes  of  uterine 
curettes,  uterine  sound,  uterine  dressing  forceps,  and  an  intra- 
uterine irrigating  tip. 

For  operations  upon  the  cervix  the  special  instruments  will 
be  a  vaginal  speculum  and  a  tenaculum.  The  sutures  will  prob- 
ably be  No.  2  chromic  catgut  or  silkworm  gut  on  a  heavy  sharp 
needle. 

This  same  preparation  will  apply  for  the  several  plastic 
operations  that  may  be  done  upon  the  vaginal  wall. 

For  suturing  the  perineum  you  will  probably  need  No.  2  plain 
or  chromic  catgut  on  a  medium-sized  round  needle,  and  silk- 
worm gut  on  a  heavy  surgeon's  needle. 

Breast. — For  the  removal  of  the  breast  the  instrument  pass- 
er's chief  concern  will  be  to  provide  plenty  of  artery  forceps  and 
ligatures.  The  sutures  will  usually  include  No,  2  plain  catgut 
on  a  surgeon 's  needle  for  the  deeper  parts,  and  silkworm  gut  on 
a  large  surgeon's  needle  for  the  skin,  and  sometimes  silk  or 
horsehair  also. 


INSTRUMENT  PASSING  309 

Lungs.— The  most  frequent  operation  will  be  for  drainage  of 
an  empyema.  For  this  you  will  need  a  periosteal  elevator  and 
a  pair  of  rib-cutting  forceps.  You  should  also  provide  a  drain- 
age tube  which  may  be  one  of  the  specially-designed  empyema 
drainage  tubes  (Fig.  17,  page  127)  or  a  plain  rubber  tube  with 
one  or  two  holes  cut  into  the  side  of  it  (Fig.  89),  and  a  safety 
pin  attached  to  keep  it  in  place.  Sometimes  the  wound  may  be 
partially  closed  with  silkworm  gut  sutures  on  a  strong  needle. 

Mastoid  Bone. — The  bone  instruments  should,  of  course,  be 
relatively  small  in  this  case  and  should  include  periosteal  ele- 
vators, chisels,  gouges,  mallet,  bone-gouging  forceps,  and  bone 
curettes.     Small  sharp  retractors  will  be  better  than  blunt  ones. 

Skin. — Skin-grafting  operations  will  require  the  provision 
of  a  special  skin-grafting  razor  or  knife,  and  it  must  be  in  per- 
fect condition.  It  will  perhaps  be  the  instrument  nurse's  duty 
to  arrange  the  grafts  after  they  are  cut  for  convenient  applica- 
tion. A  good  way  to  do  this  is  to  spread  them  out  on  rubber 
tissue  by  means  of  which  they  are  easily  picked  up  and  put  into 
place. 

Kidney. — When  the  kidney  is  to  be  removed  the  special 
instruments  will  be  a  few  long  hemostatic  forceps  and  a  tenacu- 
lum; and  heavy  catgut  (No.  4)  ligatures  on  a  ligature  carrier 
or  a  round  needle  for  the  pedicle  will  probably  be  the  suture 
material. 

When  a  stone  is  to  he  removed  from  the  kidney  a  special 
"lithotomy"  forceps  or  scoop  should  be  provided.  The  incision 
in  the  kidney  itself  will  probably  be  closed  with  fine  (No.  0  or  1) 
chromic  catgut  which  should  be  threaded  on  a  fine  round  needle. 

For  fixation  of  the  kidney  silkworm  gut  or  chromic  catgut  will 
be  the  probable  suture  material. 

The  closure  of  this  wound  will  present  no  new  problems. 

Bladder. — For  suprapubic  operation  upon  the  bladder  there 
will  probably  be  no  special  requirements  in  instruments. 
Sutures  for  the  bladder  wall  will  usually  be  of  fine  chromic 
catgut  on  a  round  needle. 

Amputations. — The  instruments  you  will  provide  are :  A  saw 
suitable  in  size  and  design  for  the  part,  a  knife  of  appropriate 
size,  periosteal  elevator,  bone  curette,  bone-cutting  and  gouging 


310  TEXTBOOK  OF  SURGICAL  NURSING 

forceps,  and  an  amputation  retractor.  Ligatures  -will,  of  course, 
correspond  in  \voiulit  to  tiie  size  of  the  stump.  Sutures  "svill 
probably,  be  of  No.  2  plain  catgut  and  silkworm  gut. 

DRAINS 

We  have  said  notliing  as  Ave  have  gone  along  about  the  prepa- 
ration of  drains  because  the  question  of  where  they  will  be  used, 
and  Avhat  kind,  if  any  at  all,  will  depend  entirely  upon  circum- 
stances. However,  as  it  "will  be  the  instrument  passer's  duty, 
as  a  rule,  to  provide  and  fashion  the  drain  we  shall  append  a 
few  comments  here  about  the  various  kinds,  (Fig.  89.)  A  spe- 
cial drainage  tube  for  empyema  cases  has  been  illustrated  in 
Fig.  17,  page  127,  and  the  student  will  find  information  about 
it  there. 

A.  Cigarette  Brain. — For  this  a  piece  of  rubber  dam  or  rub- 
ber tissue  of  suitable  size  will  be  used,  and  within  it  will  be 
rolled,  lengthwise,  cigarette  fashion,  a  piece  of  gauze  of  a  size  to 
fit  the  wound,  the  ends  of  the  gauze  being  allowed  to  project 
slightly  beyond  the  rubber  (A  of  Fig.  89). 

B.  Mikulicz  Drain. — A  square  piece  of  gauze  or  rubber  dam 
large  enough  to  line  the  entire  Avound  is  folded  as  indicated  in 
B^  of  Fig.  89 — that  is,  diagonally  several  times.  "With  a  pair 
of  sharp,  curved  scissors  small  notches  are  cut  in  this  folded 
piece  of  material  as  shown  in  B-  of  the  illustration.  For  inser- 
tion the  drain  will  be  unfolded,  and  after  it  has  been  perforated 
it  should  appear  as  shown  in  B^  of  the  illustration.  When  this 
is  in  place  in  the  wound  it  will  be  packed  full  of  gauze  packing. 

C.  Rubber  Tissue  and  Rubber  Dam. — Pieces  of  either  of 
these  materials  may  be  folded  flat  or  rolled  into  tubes  of  suit- 
able size  (C  of  Fig.  89). 

D.  Rubber  Tubing. — Pieces  of  rubber  tubing  may  be  fash- 
ioned in  various  ways  (D  of  Fig.  89).  The  gauze  packing  may 
or  may  not  be  used  in  these  drains.  The  large  drain  of  group  D 
has  the  rubber  tube  inside  of  the  gauze,  and  the  whole  is  encased 
within  a  few  layers  of  rubber  dam. 

E.  Horsehair  and  Silkworm  Gut. — A  strand  may  be  rolled 
into  a  suitable  shape  for  small  wounds  (E  of  Fig.  89). 


INSTRUMENT  PASSING 


311 


F.  Rubber  Bands, — For  small  drains  an  ordinary  rubber 
band,  either  whole  or  in  part,  may  be  used  (F  of  Fig.  89). 

G.  Gauze  Packing. — This  will  need  no  special  preparation. 
A  safety  pin  should  accompany  every  drain,  either  to  pin  it 


T 


Fig.  89. — Drains.  A,  cigarette  drain  made  of  gauze  rolled  within  a  piece 
of  rubber  tissue  or  rubber  dam;  B'^,  B^,  B^,  three  stages  in  the  evolution  of 
the  Mikulicz  drain  which  is  made  from  a  piece  of  gauze  or  rubber  dam;  C, 
rubber  tissue  or  rubber  dam  drains  made  by  folding  the  piece  flat  or  by 
rolling  it  into  a  tube;  D,  various  designs  of  rubber  tubing  drains;  E,  horse- 
hair or  silkworm  gut  drain;  F,  ordinary  rubber  band. 


fast  to  the  dressing  or  to  serve  as  a  guard  against  its  slipping 
into  the  wound  and  becoming  lost. 

A  pair  of  dressing  forceps  is,  of  course,  always  among  the 
general  instruments,  and  this  should  always  be  in  readiness  for 
the  insertion  of  the  drain. 


312  TEXTBOOK  OF  SURGICAL  NURSING 

As  we  have  warned  all  the  way  aloug,  what  we  have  given 
here  is  only  the  probable  and  the  possible.  It  Mill  now  be  the 
instrument  passer's  dut}'  to  learn  the  special  methods  of  her 
surgeon  and  to  familiarize  herself  as  widely  as  possible  with 
surgical  procedures,  and  then  she  will  be  equipped  to  supple- 
ment knowledge  with  the  good  guessing  which  every  instrument 
passer  should  always  know  how  to  practice. 


CHAPTER  XVIII 

THE    DBESSING    OF    THE    WOUND 

The  actual  dressing  of  the  wound  will  either  be  done  by  the 
surgeon  himself  or  the  specific  method  for  doing  it  will  be  pre- 
scribed by  him  if  the  nurse  is  to  do  the  work.  HoAvever,  the 
nurse  has  important  responsibilities  in  relation  to  all  wound 
dressings  and  upon  her  technic  and  general  efficiency  will 
depend  to  no  small  degree  the  simplification  of  the  treatment, 
the  comfort  of  the  patient  during  the  ordeal,  and  the  actual 
progress  of  the  wound  toward  recovery. 

Good  technic  is,  of  course,  the  most  important  thing  to  learn 
about  a  dressing,  and  the  nurse's  first  concern  should  be  so  to 
arrange  her  supplies  and  equipment  that  asepsis  will  be  more 
or  less  automatic. 

A  wound  which  has  been  sutured  and  has  had  a  day  or  more, 
as  most  of  them  will  have  had,  in  which  to  heal  somewhat,  will 
not  be  as  susceptible  to  infection  as  the  fresh  and  open  one  in 
the  operating  room;  the  time  of  exposure  for  the  dressing  is 
much  shorter  than  for  the  operation ;  and  actual  contact  with 
the  wound  is  relatively  slight.  The  extreme  precautions,  there- 
fore, of  the  operating  room  as  to  sterile  clothing  and  elaborate 
draping  are  not  called  for  in  the  dressing,  but  with  these  two 
exceptions  there  should  not  he,  and  there  need  not  he,  any  relaxa- 
tion of  rigid  aseptic  technic. 

Circumstances  and  equipment  will  determine  one's  general 
plan  for  the  preparation  of  dressing  supplies.  If  it  is  a  case 
of  a  single  dressing  the  best  method  is  to  prepare  in  a  parcel 
just  enough  supplies  for  one  dressing.  This  will  be  safest  and 
it  will  also  be  convenient.  However,  in  hospitals  where  numer- 
ous dressings  must  be  done  in  immediate  succession  there  must 
be  a  common  source  of  supply.  This  can  be  managed  by  steril- 
izing the  supplies  in  muslin-covered  parcels  and  then  transfer- 
ring them  to  glass  or  enamel  jars  which  have  been  sterilized 

313 


314 


TEXTBOOK  OF  SURGICAL  NURSING 


separately  and  whii'li  have  dust-tiglit  covers.  The  best  technic, 
however,  is  to  use  the  supplies  directly  from  the  container  in 
which  they  were  sterilized  provided  it  can  be  safely  opened  and 
closed  repeatedly.  This  will  save  much  time  and  work  and,  of 
course,  is  better  technic  in  tliat  it  eliminates  the  exposure  inci- 
dent to  the  transferral  from  one  container  to  the  other. 

There  is  a  special  meted  dressing  hox  or  drum  (Fig.  90)  which 
is  ideal  both  as  to  convenience  and  as  to  safety.    It  is  made  with 

a  catch  which  serves  to  prop 
the  lid  open  during  steriliza- 
tion and  to  close  it  securely 
afterward.  A  simple  mechan- 
ism on  the  top  of  this  box 
answers  the  double  purpose  of 
a  handle  for  carrying  it  and 
of  a  lever  for  opening  the  lid 
easily  and  safely.  This  consti- 
tutes a  very  compact  and  thor- 
oughly satisfactory  container 
in  which  can  be  stored  all  the 
gauze  and  cotton  supplies,  in- 
cluding the  draping  towels, 
and  when  it  can  be  procured 
it  should  be  used  in  preference 
to  any  other  device. 


Fig.  90.  —  Portable  Metal 
Dressing  Box.  The  bar  across  the 
top  serves  as  a  handle  for  carrying 
and  also  as  a  lever  for  opening  the 
lid,  and  it  is  so  attached  that  it 
may  be  turned  down  over  the  side 
of  the  box  out  of  the  way. 


While  this  dressing  box  is  very  safe  and  can  be  kept  cleaner 
than  any  other  container,  it  must  be  remembered  that  no  con- 
tainer which  is  opened  and  closed  frequently  can  be  considered 
sterile  indefinitely.  When  a  number  of  dressings  are  to  be  done 
at  a  time,  those  believed  to  be  "clean"  should,  of  course,  be 
done  first  and  the  infected  ones  last ;  and  the  dressing  box  thus 
frequently  exposed  during  a  considerable  period  of  time  would 
not  be  safe  to  use  further  until  resterilizecl.  The  plan  advised 
for  the  operating  room  dressing  supplies  in  Chapter  XVI,  page 
295,  will  apply  here  also,  especially  where  inexperienced  nurses 
are  concerned;  that  is,  do  not  hold  over  from  one  session  to 
another  a  used  dressing  box,  even  though  you  are  reasonably 
certain  of  its  sterility. 


THE  DRESSING  OF  THE  WOUND 


315 


The  dressing  ifistruments  will,  of  course,  be  boiled  freshly  for 
each  dressing.  The  practice,  sometimes  seen,  of  boiling  them  in 
advance,  drying  them  with  a  sterile  towel,  and  wrapping  them 
in  a  sterile  muslin  cover  for  the  next  day 's  use,  is  one  that  should 
not  be  adopted  except  in  those  instances  where  one  has  not  easy 
and  prompt  access  to  a  boiler.  As  in  the  case  of  the  operating 
room,  it  is  well  to  have  the  instrument  boiler  near  at  hand  when 
doing  dressings,  especially  when  several  are  to  be  done  in  close 
succession.  There  are  many  portable  electric  instrument  steril- 
izers on  the  market  (Fig.  91),  and  if  one  of  these  can  be  pro- 
cured and  the  suitable  connection  for  it  provided  near  the 
patient  it  makes  an  admirable  dressing  equipment.  Most  of 
these  sterilizers  have  an  attachment  which  automatically  dis- 


FiG.  91, — Portable  Electric  Instrument  Sterilizer. 


connects  the  current  in  case  they  boil  dry,  and  some  of  the  more 
recent  designs  have  a  thermostatic  mechanism  which  assumes 
entire  responsibility  for  keeping  the  water  at  the  boiling  point 
and  of  turning  off  the  current  if  the  water  supply  becomes 
exhausted. 

The  other  supplies  and  equipment  for  a  dressing  need  not  be 
taken  up  here  because  that  phase  of  the  subject  belongs  more 
particularly  to  general  practical  nursing  and  the  pupil  will  have 
learned  it  in  her  practical  course. 

To  have  all  these  necessities  conveniently  at  hand,  especially 
when  more  than  one  dressing  is  to  be  done  at  a  time,  will  call 
for  some  means  of  compact  and  easy  portability.  There  is 
always  the  tray,  of  course,  which  can  be  very  conveniently 
arranged  and  stocked,  but  when  a  variety  of  dressings  are  to  be 


316 


TEXTBOOK  OF  SURGICAL  NURSING 


clone  the  items  it  must  accommodate  Avill  be  so  numerous  and 
so  heavy  that  it  will  be  cumbersome  and  not  very  satisfactory 
generally,  In  spacious  hospital  wards  the  most  convenient  and 
technically  the  best  device  for  storing  and  transporting  supplies 
from  one  patient  to  another  is  one  of  the  dressing  carriages 
(Fig.  !)2)  Avhu-h  are  made  in  many  designs  and  sizes.  These 
carriages  have  several  shelves,  are  mounted  on  rubber-tired 
wheels,  sometimes  have  an  attachment  for  elevating  an  irrigator 


Fig.  92. — Dressing  Carriage  for  Use  in  the  Hospital  Ward. 


which  is  useful  in  Carrel-Dakin  dressings  and  other  irrigations, 
and  are  very  simple  to  Avheel  about  from  bed  to  bed.  If  one  has 
the  electric  instrument  sterilizer  and  accessible  wall  outlets  for 
its  attachment  it  may  be  kept  on  this  carriage  also  and  will  thus 
furnish  an  ideal  means  of  keeping  the  instruments  perfectly 
clean  and  ready  for  instant  use.  If  wisely  stocked  with  supplies 
and  kept  in  good  order  this  dressing  carriage  will  save  many 
precious  steps  and  wdll  enable  one  nurse  to  do  all  the  assisting 
for  a  series  of  dressings  without  the  expenditure  of  the  valuable 
time  of  a  second  errand  nurse. 

As  remarked  above,  most  of  the  other  nursing  details  of  dress- 


THE  DRESSING  OF  THE  WOUND 


317 


ings  belong  more  particularly  to  general  praeti(;al  nursing, 
but  there  are  several  points  which  will  l)ear  emphasis  from  the 
strictly  surgical  standpoint. 

Exposure  of  the  patient,  particularly  one  in  poor  condition, 
should  be  as  little  as  possible  because  it  may  have  considerable 
to  do  with  both  his  general  and  his 
local  recovery,  especially  if  the  room 
is  not  warm. 

The  removal  of  adhesive  plaster, 
especially  from  extensive  surfaces 
which  have  been  painted  with  iodine, 
calls  for  consideration  on  the  part  of 
the  surgical  nurse,  because  the  skin 
underneath  it  is  liable  to  have  be- 
come tender  and  will  therefore  be 
painful  as  the  adhesive  is  torn  from 
it;  and  sometimes  the  surface  may 
even  be  found  denuded  where  the 
plaster   has   been.      This   will   mean 

another  wound  to  care  for,  and  if  the 

.    .      ,  ,  .  .    n     X    1  xi  •  Fig.       93.  —  Adhesive 

original  wound  is  an  infected  one  this  plaster  and  Tape  Device 

new    one    may    become    troublesome,   for  Holding  Dressings  in 

Place  and  Allowing  Their 
Also,  if  the  skin  has  been  broken  removal  Without  the  Dis- 
adhesive    plaster   cannot   be    applied  ----  o.  thk  Piaster. 

again,  and  this  in  itself  will  be  at  strip  to  which  the  tape  is 

1        ,  •  •  T  attached     has    been     turned 

least    an    inconvenience.       In    cases  J^^^^.  ^.^^  ^  ^j^^^^  ^^.^^^^^^^ 

where  the  skin  shows  a  tendency  to  which     makes     this     part 
,  -ITT  stronger    and    also    prevents 

become  sore,  or  is  already  so ;  where  ^^  f roj^  adhering  to  the  skin, 

a  patient  is  particularly  disturbed  by  thus  permitting  of  its  being 

turned  back  out  or  the  way 
the  removal  of  the  adhesive ;  or  where  while   the   wound   is   being 

the  dressing  needs  to  be  changed  fre-  ^iressed. 
quently,  some  such  method  as  that  illustrated  in  Fig.  93  may 
be  used  for  keeping  the  dressing  in  place.  This  consists  merely 
of  pairs  of  adhesive  straps,  one  on  either  side  of  the  dressing, 
connected  by  tapes  which  are  tied  across  the  dressing.  These 
straps  will  remain  in  place  for  a  long  time  and  will  answer 
all  the  purposes  of  a  continuous  adhesive  strap,  except  that  of 
great  tension.  There  are  various  good  ways  of  softeiiing  ad- 
hesive plaster  before  attempting  to  remove  it.     They  all  take 


318  TEXTBOOK  OF  SURGICAL  NURSING 

more  time  than  the  (lircct  method  of  pulling  it  off,  but  in  cases 
of  sensitive,  nervous,  or  very  ill  patients,  and  often  with  children, 
it  Avill  be  necessary  to  adopt  one  of  these  gentler  methods.  Any 
oil — albolene,  or  olive  oil,  for  examples — -will  soften  the  plaster 
in  a  few  minutes  and  Avill  have  no  unpleasant  effect  ui)()n  even 
a  broken  skin.  Benzine  will  dissolve  the  plaster  more  quickly 
but  it  Avill  be  painful  if  the  skin  is  broken. 

The  general  principles  of  handling  sterile  sui)plies  for  dress- 
ings will  have  been  taught  the  nurse  in  her  practical  course  of 
instruction  and  if  she  has  had  her  operating  room  training  she 
will  know  them  well,  but  the  important  lyriuciple  of  arranging 
equipment  and  general  technic  so  as  to  reduce  the  amount  of 
handling  necessary  cannot  be  urged  too  often.  This  point  is 
not  only  imi)ortant  in  the  interest  of  asepsis,  but  it  also  saves 
much  time,  labor,  and  confusion.  A  good  standard  practice  is 
to  keep  a  pair  of  long  sterile  forceps  and  a  pair  of  scissors  for 
use  in  handling  the  sterile  supplies  in  a  tall  jar  containing  a 
solution  of  1-40  or  1-60  carbolic  acid  to  which  a  few  grains  of 
borax  have  been  added  for  the  purpose  of  preventing  rust. 
These  can  be  kept  on  the  dressing  tray  or  carriage  at  all  times, 
and  as  long  as  they  are  used  for  nothing  but  the  perfectly  sterile 
dressings  they  need  not  be  reboiled  oftener  than  once  a  day. 
The  point  that  these  forceps  and  scissors  should  be  long  ones  is 
emphasized  because  their  length  will  enable  the  nurse  to  keep 
her  unsterile  hand  well  out  of  the  region  of  the  opening  of  the 
sterile  container  and  tlius  avoid  the  possibility  of  unsterile  dust 
dropping  from  it  onto  the  sterile  supplies. 

In  this  connection  it  should  be  urged  upon  the  nurse  who 
dispenses  the  sterile  supplies  to  kee23  her  hands  as  free  from 
coniamination  as  possible.  It  will  not  be  necessary  for  her  to 
sterilize  them  but  she  should  avoid,  as  far  as  she  can,  the  removal 
of  dressings,  and  the  application  of  adhesive  plaster,  bandages, 
etc.,  after  the  dressing  is  done,  especially  in  an  infected  case, 
if  she  is  obliged  to  go  directly  to  another  wound.  If  an  assistant 
is  available  this  part  of  the  dressing  should  be  left  entirely  to 
her.  In  any  case  the  soiled  dressings  should  always  be  removed 
and  otherwise  handled  Avith  forceps.  These  forceps  need  not  be 
sterile  but  it  will  be  just  as  well  to  keep  them  in  a  jar  of  the  weak 


TUB  DRESSING  OF  THE  WOUND  319 

carbolic  solution  on  the  dressing  tray  or  carriage.  The  precau- 
tion should  be  taken  to  use  for  this  purpose  a  different  kind  of 
forceps  and  jar  from  those  provided  for  the  sterile  work. 

In  this  connection  the  nurse  usually  needs  to  be  cautioned 
about  her  technic  as  it  pertains  to  the  ubiquitous  handage  scis- 
sors. The  usual  abiding  place  of  these  indispensable  instru- 
ments, when  they  are  not  in  use,  is  the  nurse's  apron  belt  or 
pocket,  and  it  becomes  automatic  for  her  always  to  put  them 
back  there  after  use.  In  the  ordinary  everyday  work  this  is 
a  perfectly  legitimate  practice,  but  in  the  case  of  cutting  off 
infected  dressings  the  nurse  should  remember  that  her  bandage 
scissors  and  her  apron  belt  or  pocket  are  entitled  to  the  same 
technical  attention  as  her  hands  or  anything  else  she  uses,  and 
she  will,  therefore,  sterilize  her  bandage  scissors  whenever  she 
has  been  obliged  to  contaminate  them. 

Another  point  which  is  often  overlooked  is  that  solutions  used 
for  washing  or  irrigating  wounds  should  not  he  thrown  into  the 
receptacle  containing  the  gauze  dressings.  These  two  articles 
are  eventually  disposed  of  by  entirely  different  means,  the  dress- 
ings by  way  of  the  furnace  and  the  solutions  by  way  of  the  sewer. 
Thus,  if  thrown  together  they  must  be  separated  later,  which 
entails  avoidable  labor  and  very  bad  technic  in  that  much  wider 
contamination  than  is  necessary  is  caused  by  this  solution.  Two 
waste  dressing  receptacles  (preferably  pails  with  handles)  are 
necessary  if  solutions  are  used  for  a  dressing. 

As  remarked  in  the  beginning  of  this  chapter,  if  the  nurse 
dresses  the  wound  herself  she  will  have  the  guidance  of  the 
surgeon  as  to  specific  treatment,  but  she  will  need  to  exercise 
her  best  knowledge  of  asepsis  and  general  surgical  technic  on 
her  own  account. 

The  person  who  does  a  dressing  must,  of  course,  have  sterile 
hands.  The  bare  hands  may  be  sterilized  as  directed  in  Chapter 
XVI,  page  263,  or  if  sterile  rubber  gloves  are  available  they 
should  be  used  instead.  If  sterile  gloves  are  used  it  will  not  be 
necessary  to  put'  the  hands  through  the  rigid  sterilizing  process 
required  in  the  operating  room  but,  of  course,  they  should  be 
very  thoroughly  cleansed. 

All  sponging  of  the  wound,  the  handling  of  drains,  dressings, 


320  TEXTBOOK  OF  SURGICAL  NURSING 

etc.,  should  he  done  icith  forceps,  and  to  do  this  it  will  be  neces- 
sary to  provide  two  pairs  of  dressing  or  anatomical  forceps — 
one  for  each  hand.  With  a  little  practice  one  can  thus  keep  her 
gloves  entirelj'  clean  throughout  a  dressing,  and  can  do  a  number 
of  dressings  without  changing  gloves.  However,  as  a  safeguard 
against  unconscious  error,  the  gloves  sJwuld  he  given  a  thorough 
rinsing  after  each  case  in  some  antiseptic  solution,  such  as  1-1000 
bichloride. 

Some  of  the  foregoing  advice  may  seem  a  little  overdrawn,  but 
when  a  nurse  has  become  a  finished  technician  she  knows  that 
good  technic  is  as  easy  as  had  technic,  and  where  life  and  health 
are  dependent  upon  us  w^e  have  no  right  to  do  less  than  our  best. 


CHAPTER  XIX 

THE  OARREL-DAKIN  TREATMENT 

The  Carrel-Dakin  system  of  treating  infected  wounds  is  now 
so  generally  used  that  a  nurse's  surgical  education  is  not  com- 
plete unless  she  has  an  intelligent  conception  of  its  scientific 
principles  and  a  thorough  working  knowledge  of  its  detailed 
practical  application,  for  there  is  perhaps  no  other  treatment 
in  which  so  much  of  the  ultimate  success  depends  upon  the 
intelligence,  thoroughness  and  conscientiousness  of  the  nurse 
as  in  this  cg-se.  Furthermore,  while  regularly  the  dressing  and 
certain  other  parts  of  the  preparation  for  the  treatment  are 
done  by  the  surgeon,  there  will  be  occasions  when  the  nurse  will 
be  called  upon  to  do  the  dressing  herself ;  and  so,  there  is  this 
reason  in  addition  to  the  general  educational  one  for  her  acquir- 
ing as  complete  a  knowledge  as  possible  of  this  important 
subject. 

WHAT  THE  SYSTEM  IS 

The  Carrel-Dakin  treatment  may  be  defined  very  simply  as 
a  method  of  killing  the  germs  in  an  infected  wound.  You  have 
become  very  familiar  with  many  antiseptics  and  have  sterilized 
many  different  kinds  of  material  with  the  several  ones,  and  at 
first  thought  you  may  not  see  why  bichloride,  for  example, 
might  not  simply  be  applied  to  a  wound,  as  you  apply  it  to  your 
hands,  and  thus  kill  its  germs.  The  tissues  of  a  wound,  however, 
give  us  a  very  different  proposition  from  that  of  the  healthy 
surface  of  your  hands. 

In  the  first  place,  yaw  always  wash  your  hands  very  thor- 
oughly with  soap  and  water  to  remove  everything  but  the 
healthy,  clean  surface  of  them  before  you  expect  bichloride  to 
serve  you ;  and  since  soap  and  w^ater  constitute  a  very  good 
disinfectant  on  their  own  account,  you  have  thus  greatly  reduced 
the  task  for  the  bichloride. 

321 


322  TEXTBOOK  OF  SURGICAL  NURSING 

Secondly,  the  tissues  of  a  wound  arc  a  literal  culture  medium 
for  the  germs,  and  this  means  that  there  is  present  in  the  wound, 
besides  the  germs  themselves,  the  dead  tissue  wliich  they  have 
destroyed  in  the  process  of  their  feeding  upon  it,  and  all  the 
other  waste,  "\\hirli  you  have  learned  about  in  Chapter  I,  that 
accompanies  inflammation  and  infection. 

Furthermore,  a  great  deal  of  this  material  is  not  on  the  sur- 
face of  the  ivound  but  permeates  its  walls  to  a  greater  or  lesser 
depth.  Thus,  you  see,  even  though  we  were  able,  as  we  sometimes 
are,  to  wash  the  wounds  as  j^ou  do  your  hands,  we  could  not 
reach  the  "soiled"  parts  that  are  within  the  tissues  themselves, 
and  could  not,  therefore,  expect  our  bichloride  to  accomplish 
much  in  these  parts. 

More  than  this,  bichloride,  as  is  true  of  all  the  other  powerful 
antiseptics  which  you  have  used,  is  very  irritating  to  the  tissues 
and  while  it  was  destroying  the  germs  it  would  also  destroy,  or 
at  least  devitalize,  the  good  tissue  which  it  reached.  You  have 
doubtless  learned  this  in  the  case  of  your  own  hands  which  have 
become  sore  or  have  developed  a  rash  Avhen  you  have  had  to 
use  it  frequently.  Bichloride  has  been  used  only  as  an  example 
and  you  would  find  that  carbolic  acid,  formalin,  or  any  other 
known  antiseptic  that  is  at  all  powerful  would  act  similarly. 
Also,  your  hands  have  been  only  an  example  with  which  can 
be  compared  all  the  various  articles  which  you  are  in  the  habit 
of  sterilizing  with  an  antiseptic  solution. 

Another  more  complex  and  abstruse  problem  which  enters 
into  this  subject  is  that  of  actually  getting  a  solution  of  any 
kind  into  the  tissues  themselves,  even  "clean"  ones.  Those  of 
you  who  have  studied  physics  and  chemistry  will  know  from 
what  you  have  learned  about  "osmotic  pressure"  that  there  is 
a  great  difference  among  the  powers  of  solutions  to  permeate  any 
given  material.  This  may  be  demonstrated  by  taking  a  jar  with 
a  partition  of  some  permeable  membrane,  parchment  paper,  for 
instance,  through  the  middle  of  it,  and  pouring  into  one  side  a 
colored  solution  of  salt  in  water  and  into  the  other  side  plain 
water,  and  then  watching  them  mix.  Each  solution  permeates 
through  the  membrane  into  the  other  compartment,  and  in  this 
case  the  water  permeates  more  rapidly  than  the  colored  salt 


THE  CARREL-DAKIN  TREATMENT  323 

solution  because  the  water  is  the  less  dense;  solution,  or,  as  we 
say,  has  less  "osmotic  pressure."  If  we  put  the  same  solution 
into  the  two  compartments  they  will  mix  equally  because,  of 
course,  their  "osmotic  pressures"  are  equal.  Similarly,  if  we 
put  two  different  solutions  having  the  same  density  into  the 
two  compartments  they,  too,  would  mix  equally  because  they 
had  the  same  "osmotic  pressure."  In  the  study  of  physiology 
the  blood  serum  is  taken  as  the  standard  fluid  for  all  compari- 
sons of  this  kind  and  any  fluid  which  has  the  same  "osmotic 
pressure"  as  the  blood  serum  is  said  to  be  ^'isotonic"  with  the 
blood.  This  term  ' '  isotonic ' '  is  one  which  nurses  often  hear  and 
they  should  know  its  meaning,  especially  if  they  wish  to  under- 
stand one  of  the  great  hidden  secrets  of  the  efficacy  of  the  Dakin 
solution. 

The  fact,  then,  which  we  have  just  tried  to  prepare  you  to 
understand  is  that  another  great  reason  why  bichloride,  car- 
bolic acid,  formalin,  etc.,  will  not  sterilize  an  infected  wound 
is  because  they  are  not  ' '  isotonic ' '  with  the  blood  serum  and  will 
not,  therefore,  mix  well  with  it  through  the  permeable  "mem- 
brane" we  have  in  the  case  of  wounds — the  body  tissues. 

Consequently,  in  order  to  sterilize  an  infected  wound  we  have 
to  devise  some  means,  first,  of  "washing"  it  as  best  we  can,  and 
then  of  applying  to  it  a  solution  which  has  the  power  of  killing 
its  germs  whether  they  are  on  its  surface  or  more  or  less 
entrenched  within  its  tissues.  This  Drs.  Carrel  and  Dakin 
have  done  for  us  in  great  detail  in  the  Carrel-Dakin  system  of 
wound  disinfection. 

HISTORY 

The  method,  as  a  whole,  is  the  invention  of  Dr.  Alexis  Carrel, 
the  distinguished  American  biologist  who,  since  his  emigration 
to  this  country  in  1905  from  his  native  land,  France,  has 
repeatedly  commanded  the  attention  and  admiration  of  scientists 
the  world  over  by  his  brilliant  and  serviceable  experiments  and 
discoveries  in  the  art  of  surgery,  carried  on,  for  the  most  part, 
at  The  Rockefeller  Institute  for  Medical  Research,  in  New  York. 

The  Carrel-Dakin  treatment  was  introduced,  however,  on  the 
battlefield,  in  the  beginning  of  the  European  war,  by  Dr.  Carrel 


324 


TEXTBOOK  OF  SURGICAL  NURSING 


at  his  Frencli  Ann\-  liospilal,  t'oiiiulcd  by  llic  Rockefeller  Insti- 
tute at  Corapiepnr,  Kfjiiicc.  In  tliis  woi-k  he  had  llie  eollabora- 
tiori  of  Dr.  Dakin  who  did  inueh  of  tlu'  laboratory  experimenta- 
tion necessary  to  perfect  the  remarkable  solution  Avliich  Dr. 
Dakin  had  <>iven  to  the  profession  some  time  previously  and 
which  bore  his  name.  In  time  the  treatment  was  adopted  by 
several  other  French  Armj'  surgeons  and  became  an  established 
treatment  in  their  war  hospitals.  Because  of  its  exacting  and 
somewhat  tedious  technic,  however,  and  through  hesitancy  to 
institute  radical  changes  in  procedure,  the  method  was  rather 
slow  of  adoption  by  surgeons  in  general,  but  its  beneficence  has 
become  such  an  established  fact  that  it  is  now  in  fairly  general 
use. 


Before  taking  up  the  study  of  the  system  as  a  whole  we  shall 
take  time  to  gather  together  and  learn  about  the  tools  we  shall 
need,  for  when  we  have  all  this  in  mind  the  remainder  of  the 


Fig.   94. — ^Dressing   Forceps   for    Use   in  Dressing  the    Carrel-Dakin 

Wound. 

text  will  be  more  intelligible ;  and  as  this  is  the  part  of  the 
Carrel-Dakin  method  with  which  the  nurse  is  most  concerned 
in  practice,  special  emphasis  put  upon  these  details  before  think- 
ing of  anything  further  will  be  a  good  initial  investment. 


EQUIPMENT 

For  the  administration  of  this  treatment  a  considerable  num- 
ber of  articles  are  needed,  and  experience  will  teach  that  none 
of  them  can  be  omitted  without  serious  handicap  following. 

The  necessary  items  are  these : 

1.  Instruments:  4  pairs  of  long  dressing  forceps  (Fig.  94) 
and  2  pairs  of  long  scissors ;  all  sterile,  of  course. 


THE  CARREL-DAKIN  TREATMENT 


325 


2.  A  small  sterile  basin  of  Dakin's  solution. 

3.  A  jar  of  sterile  vaseline-gauze  strips. 

4.  Sterile  rubber  delivery  tubes   (Fig.  95). 

5.  Small  sterile  gauze  dressings. 


0 

•    .  •  .    •  .  •  .  •>3 

A' 

0 

■    .  ■  .  •   .'.--i 

A- 

0 

• 

V^   \  \  ]   \  \  \\) 

,B 

0 

c^   <■    ^ 

:p 


Fig.  95.— The  Rubber  Delivery  Tubes.  A\  closed  at  the  end  by  tying; 
A^,  closed  at  the  end  by  stitching ;  B,  made  the  same  as  A"^  or  A^  and  after- 
ward wrapped  with  gauze  or  Turkish  toweling;  C,  the  end  cut  at  an  angle 
and  a  large  opening  cut  in  one  side  near  this  end;  D,  a  longer  tube  per- 
forated in  the  middle,  and  connected  at  the  ends  to  a  glass  Y-tube. 


326 


TEXTBOOK  OF  SURGICAL  NURSING 


6.  Large  sterile  gauze  dressings. 

7.  Sterile  cotton  pads. 

8.  Sterile  safety  pins. 


^ 


3 


Fig.  96. — Eeservoirs  for  the  Dakin  Solution.  A,  a  glass  graduated 
one  which  may  be  securely  stopped  with  a  cork;  B,  a  flat-bottomed  one 
made  of  enameled  metal. 


Fig.  97. — Glass  Syringes  for  Administering  the  Dakin  Solution. 
A,  rubber  bulb  type  which  may  be  operated  with  one  hand— the  most  con- 
venient one  for  the  purpose;  B,  the  more  common  plunger  type. 

9.  Bandages. 

10.  Irrigator  stand  (Fig.  44,  page  221). 

11.  Reservoir  for  Dakin 's  solution    (Fig.   96). 

12.  Glass  syringe  (1-ounce  size)    (Fig.  97), 


THE  CARREL-DAKIN  TREATMENT 


327 


13.  Rubber  tubing — enough  to  reach  generously  from   the 
reservoir  to  the  wound, 

14.  Stopcock  (spring  or  screw)   (Fig.  98). 


A  B 

Fig.  98. — Stopcocks  for  Use  on  the  Supply  Tubing  in  the  Eeservoir 
Method  of  Administering  the  Dakin  Solution.  A,  metal  spring  va- 
riety, suitable  for  the  intermittent  method,  as  it  always  entirely  closes  off 
the  tube;  B,  screw  variety,  suitable  for  the  continuous  method  of  instil- 
lation, as  the  rate  of  flow  of  the  solution  can  be  very  exactly  controlled 
with  it. 


CC 


X::^     CX 


OC 


cc 


im' 


Fig.  99. — Glass  Connecting  and  Distributing  Tubes.  A,  ordinary 
straight  splicing  tube;  B,  suitable  for  connecting  rubber  tubes  of  dif- 
ferent calibers,  as  in  the  case  of  uniting  one  of  the  small  wound  tubes 
directly  to  the  main  supply  tube.  This  tube  also  answers  as  a  dropper 
tube  in  place  of  the  special  one  illustrated  in  Fig.  100;  C,  Y-tube  for 
making  various  bifurcations  in  the  main  supply  tube;  D,  E,  and  F,  2-,  3-, 
and  4-way   tubes  for   connecting   the   wound   tubes  with   the   supply   tube. 

15.  Glass  connecting  and  distributing  tubes  (straight,  Y- 
shaped,  2-,  3-,  and  4-way)    (Fig.  99). 

16.  Glass  dropper  tube  (Fig.  100). 


328 


TEXTBOOK  OF  SURGICAL  NURSING 


1.  Instruments. — For  the  drossinor  the  forceps  and  scissors 
should  be  long  ones  so  as  to  make  it  possible  to  keep  the  hands 
-well  aAvav  from  tlie  ^vol^nd  and  dressings.  The  best  type  of 
dressing  foreeps  is  the  one  illustrated  in  Fig.  94.  Four  pairs 
are  provided,  as  both  the  person  -who  dresses  the  wound  and  the 
assistant  -will  use  a  pair  in  each  hand. 

2.  Solution  Basin. — This  may  be  of  any 
material  that  is  easily  steriliza'bJe,  but  as  Da- 
kin's  solution  deteriorates  upon  exposure  to 
light  it  is  advisable  to  select  a  dish  made  of 
an  opaque  material  and  one  having  a  cover. 
An  enamel-ware  covered  dish  which  holds  a 
pint  will  be  a  good  one  for  the  average  pur- 
pose.    This  should  be  sterilized  by  boiling. 

3.  Vaseline  Gauze. — Probably  the  best 
gauze  for  this  purpose  is  bandage  gauze,  as  the 
material  used  must  have  more  body  than  the 
average  dressing  gauze  has.  The  size  of  the 
pieces  will  doubtless  be  prescribed  by  the  in- 
dividual surgeon,  as  preferences  vary,  but  an 

Fig.  100.— Glass   average  suggestion  would  be  to  cut  a  2-inch 

Dropper  Tube  for  bandage  into  6-inch  lengths.     Turn  back  one 

Use  on  the  Main  °  ^ 

Supply    Tube    in    end   of  each  strip   a  half  inch   or   more ;   the 

Continuous  Meth-   reason  for  this  is  that  it  can  be  picked  up  more 

The    solution  g^sily  after  it  has  been  impregnated  ■with  the 

not        pass  ''  1      o 


Lay  these  in  a  neat  rank,  the  piece 
ck  lying  on  top  each  time, 
this  dish  may  be  of  any 


OD. 

can 

througli   this  tube  vaseline. 

faster     than     drop  ,  ,  t  i       i    i    •  ,  i     .• 

by   drop,   and  the  yo^^'  have  turned  back  lymg  on  top  each  time, 

rate  at  which  it  is    j^    ^    shallow    dish 

dropping     can     be 

readily  observed  at  material  that  will  withstand  the  steam  pressure 

of  the  autoclave,  it  must  have  a  cover,  and  it 

will  be  found  more  satisfactory  to  have  it  of  a  length   and 

breadth  only  slightly  larger  than  the  gauze  strips.     Melt  the 

vaseline   (preferably  the  white  vaseline)   and  pour  it  over  the 

gauze,  using  only  enough  to  cover  it.     It  might  be  mentioned 

that  the  dish  containing  the  gauze  should  be  warm  when  the 

melted  vaseline  is  poured  into  it  so  that  a  good  permeation  of 

the  gauze  will  take  place  then,  when  the  proper  amount  needed 

must  be  judged.    This  is  then  sterilized  in  the  autoclave  for  the 


THE  CARREL-DAKTN  TREATMENT  329 

maximum  time  used  for  the  other  dressings.  We  would  em- 
phasize the  superiority  of  this  method  of  prei)aring  the  gauze 
over  several  other  methods  in  practice,  as  it  eliminates  all  han- 
dling after  sterilization.  If,  for  any  reason,  this  technic  cannot 
be  carried  out,  however,  the  three  items  may  be  sterilized  separ- 
ately by  the  best  available  method  and  combined  after- 
ward. 

4.  Delivery  Tubes. — Select  for  these  tubes  a  soft  rubber 
tubing  of  about  the  No.  14  or  15  French-scale  size.  This  tubing 
must  not  be  too  stiff  to  adjust  easily  in  the  wound,  nor  so  soft 


Fig.  101. — The  Way  to  Perforate  the  Wound  Tube.  This  particular 
punch  is  made  for  the  purpose,  but  any  similar  one  which  makes  a  hole  about 
%  millimeter  in  diameter  will  do.  Two  holes  are  made  at  a  time  in  this 
way  at  directly  opposite  points  on  the  walls  of  the  tube.  The  next  two 
will  be  made  at  a  distance  of  about  half  an  inch  from  these,  and  in  a  line 
at  right  angles  to  theirs. 

as  to  be  easily  compressed  by  dressings,  angles  of  the  wound, 
etc.  Cut  the  tubing  into  lengths  ranging  from  12  to  16  inches 
(the  length  will  be  governed  by  the  character  and  location  of 
the  wound),  and  then  fashion  these  pieces  into  whichever  of  the 
following  varieties  you  need  for  your  particular  case : 

Tube  A.  Close  one  end,  either  by  tying  (A^  of  Fig.  95)  as 
near  as  possible  to  the  end  with  a  strong  thread  (linen,  prefer- 
ably), or  by  taking  two  short  stitches  (A^  of  Fig.  95)  at  right 
angles  over  the  end.  With  a  sharp  punch,  about  %  millimeter  in 
diameter,  perforate  the  tubes  (Fig.  101)  for  distances  varying 
from  2  to  8  inches  (depending  upon  the  extent  of  the  wound) 
from  the  tied  end,  taking  care  to  distribute  the  perforations  as 


330  TEXTBOOK  OF  SURGICAL  NURSING 

evenly  as  possible  over  the  surface  of  the  tube,  and  making 
about  4  holes  to  each  iiu-h  ol"  tul)ino'.  Do  not  attempt  to  make 
these  holes  with  a  hot  needle,  as  this  may  leave  loose  pieces  of 
burnt  rubber  in  the  tube  whieli  would  later  become  foreign 
bodies  in  the  wound.  There  is  no  substitute  for  the  punch 
which  removes  entirely  a  small  piece  of  the  rubber.  This  tube 
is  used  as  you  now  see  it,  but  for  some  purposes  it  needs  a  fur- 
ther modification  thus : 

Tube  B.  Over  the  perforatitms  of  the  tube  described  above 
wind,  bandage  fashion  (B  of  Fig.  95)  a  strip  of  soft  gauze,  or, 
as  Dr.  Carrel  originally  prescribed,  a  piece  of  Turkish  toweling. 
The  toweling  is  not  always  at  hand,  and  soft  gauze  makes  a 
good  substitute.  Tlie  amount  applied  will  necessarily  vary  with 
the  wound,  but  a  good  average  amount  would  be  6  or  8  layers. 
It  will  be  a  wise  precaution  to  .stitch  this  gauze  at  one  end  to 
the  tube  to  prevent  its  being  lost  in  the  wound.  This  tube  will 
be  used  in  cases  where  the  solution  has  to  be  carried  uphill,  the 
gauze  serving  the  purpose  of  holding  the  solution  in  contact 
with  the  wound  surface. 

Tuhe  C.  Leave  both  ends  open,  cut  one  end  at  an  angle,  and 
about  Yq  inch  from  this  end  cut  a  small  hole  (C  of  Fig.  95) 
with  a  pair  of  scissors,  making  the  tube  resemble  an  open-end 
rectal  tube.  This  tube  will  be  used  in  deep,  narrow  wounds 
where  all  one  needs  to  do  is  to  fill  the  cavity  with  the  solution. 
Or,  if  the  continuous  method  of  administration  is  used,  this 
will  be  the  most  serviceable  tube. 

Tube  D.  This  tube  should  be  about  twice  as  long  as  the 
others,  and  it  is  perforated  in  the  middle  (D  of  Fig.  95)  instead 
of  at  one  end.  The  solution  is  carried  into  this  tube  at  both  ends 
by  means  of  a  glass  Y-tube  (C  of  Fig.  99)  and  the  loop  thus 
formed  is  used  for  surface  wounds. 

These  tubes  are  best  sterilized  in  clear  boiling  water,  and  15 
minutes  is  enough  time  to  give  them,  for  every  nurse  knows  that 
rubber  articles  deteriorate  soon  under  anj^  method  of  steriliza- 
tion. 

5.  Small  Gauze  Dressings. — For  this  dressing  the  small 
gauze  sponge  or  "wipe"  which  is  provided  for  general  sponging 


THE  CARREL-DAKIN  TREATMENT  331 

will  serve.    This  will  be  used  as  Dakin  packing  in  many  wounds 
in  cooperation  with  the  tubes. 

6.  Large  Gauze  Dressings. — These  will  simply  be  large 
folded  gauze  dressings  of  a  size  a^d  shape  to  generously  cover 
the  wound. 

7.  Cotton  Pads. — These  pads  are  very  important  adjuncts 
and  should  be  made  with  care  and  foresight  as  to  size,  shape,  and 
thickness.  There  should  be  a  generous  layer  of  absorbent  cotton, 
a  thinner  one  of  non-absorbent  cotton,  and  these  should  be 
securely  covered  with  a  layer  of  gauze.  Their  size  and  proi^or- 
tions  will  vary  with  the  size,  nature,  and  location  of  the  wound, 
but  they  should  always  be  large  enough  to  extend  well  beyond 
the  gauze  dressings  on  all  sides,  and  if  the  wound  is  so  situated 
that  there  may  be  drainage  downward,  as  in  the  case  of  the 
extremities,  this  pad  should  be  large  enough  to  envelop  the  part 
entirely. 

All  gauze  and  cotton  dressings  will,  of  course,  be  sterilized 
in  the  steam  autoclave. 

8.  Safety  Pins. — It  is  important  that  these  should  be  steril- 
ized either  by  dry  heat,  or  by  boiling  immediately  before  use 
so  as  to  be  sure  that  they  are  free  from  rust. 

9.  Bandages. — There  should  be  a  supply  of  sterile  bandages 
on  hand,  as  in  some  cases  it  is  necessary  to  use  them  where 
sterility  is  obligatory. 

10.  Irrigator  Stand. — In  the  hospital  the  provision  of  a  suit- 
able stand  presents  no  problem  (see  Fig.  44,  page  221),  but  in 
the  home  and  other  places  one  can  always  find  a  costumer,  a 
chandelier,  a  bed  post,  chiffonier,  or  any  number  of  other  sup- 
ports which  can  be  utilized  for  raising  the  solution  the  required 
height  above  the  patient. 

11.  Reservoir  for  Solution. — ^IVIany  authorities  advise  a  glass 
irrigating  jar  (A  of  Fig.  96)  for  this  purpose,  and  if  it  is  small 
and  graduated  in  ounces  or  cubic  centimeters  it  is  a  good  one; 
but  if  it  is  large  it  seems  a  little  inconsistent,  inasmuch  as  the 
Dakin  solution  is  known  to  deteriorate  when  exposed  to  light, 
and  if  one  puts  as  much  as  a  quart  in  this  jar  it  is  evident  that 
the  last  portions  of  this  quantity  used  will  have  been  exposed 
for  many  hours.     Another  objection  to  the  glass  containers  is 


332  TEXTBOOK  OF  SURGICAL  NURSING 

that  most  of  tlieni  are  not  fiat-bottomed  and  eannot,  therefore, 
be  elevated  by  any  means  but  suspension  whieh  might  not  always 
be  convenient.  Tlie  graduated  glass  jar,  however,  is  an  advan- 
tage in  that  it  enables  one  to  see  the  amount  of  the  solution  that 
is  being  injected  at  each  instillation;  but  in  the  average  case 
perhaps  the  article  most  easily  obtained  will  be  the  simple 
enameled  metal  irrigator  with  a  flat  bottom  and  an  outlet  in  the 
form  of  a  tube  projecting  from  the  side  (B  of  Fig.  96).  This 
is  easily  sterilized  by  hoilivg,  and  if  not  provided  with  a  ready- 
made  cover  a  heavy  cloth  cover  can  be  fitted.  Tlie  most  service- 
able size  in  this  type  of  irrigator  will  be  one  that  holds  a  quart. 
This  irrigator,  as  well  as  the  glass  ones,  may,  of  course,  be 
sterilized  hy  steam,  or  hy  soaking  in  some  antiseptic  solution, 
such  as  bichloride. 

We  would  caution  the  nurse  against  the  temptation  which  may 
come  to  her  in  a  private  house  to  use  a  rubber  douche  bag  lor 
the  reservoir.  All  concerned,  including  the  bag,  would  come 
to  grief  within  a  very  short  time  as  the  Dal<;in  solution  finds 
weak  places  in  rubber  sooner  than  any  other  solution. 

12.  Glass  Syringe. — This  will  be  needed  only  when  the  solu- 
tion is  administered  by  the  syringe  method  instead  of  by  reser- 
voir. It  is,  of  course,  necessary  to  provide  an  individual  syringe 
for  each  wound.  The  capacity  should  be  from  1  to  2  ounces; 
a  smaller  one  is  too  trifling,  and  a  larger  one  may  be  too  force- 
ful (Fig.  97).  Of  these  two  syringes  A  of  the  illustration  is 
the  better  model  because  it  can  be  manipulated  with  one  hand, 
which  will  always  be  a  great  advantage  as  the  other  hand  will 
be  free  to  control  and  steady  the  wound  tube.  These  are  steril- 
ized by  boiling. 

13.  Rubber  Tubing. — The  red  rubber  tubing  seems  to  be 
the  best  quality  for  this  purpose.  One  piece,  long  enough  to  allow 
considerable  slack  between  the  reservoir  and  the  delivery  tubes, 
should  be  provided,  and  there  should  also  be  on  hand  several 
shorter  pieces.  This  rubber  should  be  in  perfect  condition,  as, 
at  its  best,  it  does  not  withstand  the  Dakin  solution  well,  and  a 
small  defect  will  soon  play  havoc  with  the  patient's  comfort, 
the  bed,  and  the  nurse 's  time.  The  caliber  of  this  supply  tubing 
should  be  a  few  sizes  larger  than  that  of  the  wound  tubes,  or,  a 


THE  CARREL-DAKIN  TREATMENT  333 

No.  18  or  20,  Frencli-scale.  Sterilize  this  by  boiling  for  10 
minutes  in  clear  water.  Of  course,  if  the  solution  is  to  be 
administered  by  syringe  this  tubing  may  not  be  needed. 

14.  Stopcock. — This  must  be  in  perfect  condition,  and  many 
should  be  in  reserve  as  the  solution  rusts  them  quickly.  When 
the  treatment  is  given  intermittently  these  stopcocks  should  be 
of  the  metal  spring  variety  (A  of  Fig.  98),  but  when  the  con- 
tinuous method  is  used  the  screw  variety  (B  of  Fig.  98)  is  best, 
as  it  permits  of  better  control  of  the  flow. 

15.  Glass  Connecting'  and  Distributing  Tubes. — There 
should  be  a  generous  supply  of  all  the  varieties  illustrated  in  Fig. 
99.  Special  attention  is  called  to  the  tube  with  the  one  fine,  taper- 
ing end,  B  of  the  illustration,  which  should  be  used  on  the  main 
supply  tube  when  the  drop  method  is  used  and  a  special  dropper 
tube  (Fig.  100)  is  not  available.  It  is  not  advisable  to  use  a 
distributing  tube  of  more  than  4  divisions,  as  a  greater  number 
of  the  rubber  delivery  tubes  in  one  group  is  clumsy  and  difficult 
to  adjust. 

These  tubes  can  all  be  'boiled,  but  they  should  be  well  wrapped 
in  a  towel  or  some  similar  material  to  avoid  breakage,  and  they 
should  be  put  into  the  water  before  it  is  heated  to  avoid  the 
same  calamity. 

16.  Glass  Dropper  Tube. — This  is  a  great  convenience 
(Fig.  100)  in  the  continuous  method  but  not  a  necessity,  as  any 
nurse  who  has  administered  the  Murphy  drip  must  have  discov- 
ered when  she  has  had  to  proceed  with  the  treatment  after  she  has 
broken  the  only  tube  she  had,  or  it  has  refused  to  function  for 
some  unknown  reason. 


The  nurse  has  now  prepared,  sterilized,  and  assembled  ready 
for  use  all  the  necessary  equipment  for  the  treatment,  and  we 
can  proceed  with  the  study  of  the  system. 

THE  FOUR  PROCESSES   OF  THE  SYSTEM 

It  must  be  learned  in  the  beginning  of  this  subject  that  the 
complete  Carrel-Dakin  system  embraces  more  than  the  mere 
application  of  an  antiseptic  to  a  wound.    This  is  an  exceedingly 


334  TEXTBOOK  OF  SURGICAL  NURSING 

inipoi-tant  part  oF  the  teclmic,  l)ut  it  t-ould  not  siu'cood  out  of 
cooperation  witli  the  three  other  procedures  \vhi('li  go  ^vitll  it 
to  make  the  Avhole.  The  four  processes,  then,  Avhicli  make  up 
the  complete  system  are  : 

I.  Dchridement.  IT.  Administration  of  the  Dakin  Solution 
to  the  Infected  Wound.  III.  The  Periodical  Bacteriological 
Examination  of  the  ^Xound.  IV.  The  Suturing  of  the  Wound 
When  Sterile. 

I.  DEBEIDEMENT 

As  outlined  above,  the  Carrel-Dakin  teelniic  proper  begins 
■with  the  surgical  operation  called  " dehridement,"  which  is  a 
French  word  meaning,  in  the  words  of  the  International  Dic- 
tionary, "Operation  of  removing  by  an  incision  any  part  which 
causes  obstruction  or  prevents  escape  of  pus."  This  operation, 
however,  as  applied  here  by  Dr.  Carrel,  involves  a  little  more 
than  the  above  definition  implies,  for  by  ''debridement"  Dr. 
Carrel  means  a  very  thorough,  delicate,  and  rigidly  aseptic 
removal  from  the  wound  at  the  very  earliest  possible  moment 
of  all  foreign  material,  infected  tissue,  injured  tissue  which 
might  easily  become  infected,  and  also  as  much  good  tissue  as 
might  stand  in  the  way  of  the  thorough  application  of  the 
Dakin  solution  to  absolutely  every  part  of  the  wound.  In  other 
words,  when  the  surgeon  "debrides"  a  wound  he  operates  as 
soon  as  he  can,  uses  and  exacts  the  most  rigid  aseptic  technic 
possible,  and  under  these  conditions  lays  the  wound  widely  open, 
takes  out  all  foreign  bodies,  dirt,  etc.,  and  then  cuts  away  all 
dead  and  injured  tissue  and  whatever  good  tissue  may  be  neces- 
sary to  give  him  reasonably  good  access  to  everj'  remote  part  of 
the  wound,  using  great  care  throughout  not  to  cause  any  more 
injury  to  the  good  tissue  than  is  absolutely  necessary  to  gain 
his  end;  and  when  he  is  through  he  has  a  wound  that  contains 
nothing  but  living,  and,  so  far  as  the  eye  can  see,  healthy  tissue. 

The  first  step  in  the  treatment  has  now  been  taken — the  wound 
has  been  "debrided"  and  as  much  of  the  infection  has  been 
removed  as  is  possible  by  means  of  pure  surgery. 


THE  CARREL-DAKIN  TREATMENT  335 

11.  ADMINISTRATION  OF  THE  DAKIN  SOLUTION 

This  subdivision  of  the  method  involves  a  group  of  procedures 
which  we  shall  classify  as  follows: 

1.  Dressing  of  the  Wound. — a.  Vaseline  Gauze,  h.  The  De- 
livery Tuhes.    c.  The  Gauze  and  Cotton  Dressings. 

2.  Adjustment  of  Instillation  Appliances. — a.  For  the  Res- 
ervoir Intermittent  Method,  b.  For  the  Reservoir  Continuous 
Method,     c.  For  the  Syringe  Method. 

3.  Instillation  of  the  Dakin  Solution. — a.  The  Reservoir  In- 
termittent 3Iethod.  1).  The  Reservoir  Continuous  Method. 
c.  The  Syringe  Method. 

1.  Dressing  of  the  Wound.— It  may  seem  to  you,  after 
learning  of  the  thoroughness  with  which  the  debridement  was 
done,  that  the  wound  should  now  be  free  from  germs  and  that 
healing  would  take  place  in  the  natural  course  of  events.  Or,  if 
you  accepted  doubt  on  this  point  you  might  hold  that  we  could 
determine  whether  or  not  there  still  remained  infection  by  taking 
a  culture  of  this  clean  and  healthy-looking  wound.  This  conten- 
tion would  not  be  quite  sound,  however,  because  of  the  fact  that 
infection  does  not  develop  and  become  active  for  a  day  or  two, 
and  so,  in  order  to  play  safe,  the  stage  is  set  immediately  for 
the  instillation  of  the  antiseptic  solution. 

a.  The  Vaseline  Gauze. — The  first  step  is  to  apply  the  vase- 
line gauze  strips  to  the  skin  immediately  surrounding  the  wound. 
The  skin  becomes  irritated  in  a  short  time  if  subjected  to  a 
constant  bath  of  the  combination  of  Dakin 's  solution  and  the 
wound  excretions,  and  for  this  reason  all  parts  likely  to  be 
exposed  to  drainage  must  be  carefully  covered  with  the  vaseline 
gauze  which  is  impervious  to  it  (Fig.  102). 

The  assistant,  a  pair  of  dressing  forceps  in  each  hand,  picks 
up  the  end  of  the  vaseline  gauze  strip  which  she  turned  back 
when  she  packed  it,  pulls  the  piece  loose  from  the  others  and 
immediately  grasps  the  other  end  with  the  pair  of  forceps  in 
the  other  hand.  She  passes  it  thus  to  the  person  dressing  the 
wound;  he,  also,  has  a  pair  of  dressing  forceps  in  each  hand. 


336  TEXTBOOK  OF  SURGICAL  NURSING 

These  strips  are  then   i)r(>ssed  smoothly  and  closely  upon  the 
needful  parts  as  pointed  out  above. 

h.  The  Delivery  Tubes. — Next,  the  rubber  Avound  tubes  are 
put  into  place.  The  size,  shape,  location,  and  general  character 
of  the  wound  will  determine  Avhieh  of  the  four  kinds  of  delivery 
tubes  you  have  provided  will  be  used  (Fig.  103).  In  some  cases 
you  may  be  called  upon  for  more  than  one  kind  for  the  same 
wound. 

Tuhe  A  (Fig.  95)  is  the  most  frequently  used  one  because  it 
can  be  adapted  to  the  greatest  variety  of  wounds  and  can  be 
best  fitted  into  the  more  shapeless  ones   (see  A  of  Fig.  103). 


Fig.  102. — The  Wat  to  Lay  the  Vaseline  Gauze  Strips  Around  the 
Margin  of  the  Wound. 

HoAvever,  if  the  wound  is  in  such  a  position  that  it  will  not  hold 
the  solution  until  it  is  absorbed — -in  other  words,  if  it  is  not 
right-side-up,  as  one  on  the  lower  part  of  the  leg  or  arm,  or  on 
the  back — tube  B  (Fig.  95)  will  have  to  be  used  (see  B  of  Fig. 
103),  and  the  gauze  which  you  have  wrapped  around  it  will  serve 
as  a  storehouse  which  will  supply  the  solution  to  the  tissues  as 
fast  as  they  can  absorb  it.  Some  of  the  small  gauze  dressings 
which  you  have  provided  may  also  be  used  in  this  case  to  fill 
in  the  wound  or  to  keep  the  tubes  in  place.  It  should  be  remem- 
bered that  when  this  gauze  is  used  it  should  be  saturated  with 
the  Dakin  solution  before  it  is  inserted.  Also,  when  tube  B  is 
used  the  gauze-wound  end  should  be  dipped  into  the  solution 
before  insertion.  The  solution  basin  mentioned  above  is,  of 
course,  used  for  this  purpose. 

If  the  wound  is  a  relatively  smooth-walled  one,  and  will  hold 


TPIE  CARREL-DAKIN  TREATMENT 


337 


g  2  bc' 


338  TEXTBOOK  OF  SURGICAL  NURSING 

the  solution,  tube  C  (Fig.  95)  is  used  (see  C  of  Fig.  103),  and 
some  of  the  small  gauze  dressings  may  be  tucked  around  it  to 
keep  muscles  or  other  structures  from  closing  in  upon  it  and 
obstructing  it,  though  when  this  is  done  the  gauze  should  be 
so  placed  that  it  does  not  come  Ix'iween  the  tube  openings  and 
the  wound  surface,  as  it  is  likely  to  become  clogged  with  wound 
excretions  and  will  then  be  impervious  to  the  solution. 

In  the  case  of  a  shallow  ivound  on  the  surface,  especially  if  it 
is  extensive,  one  or  more  of  tube  D  (Fig.  95)  will  be  used  (see 
D  of  Fig.  103),  a  thin  layer  of  gauze  being  first  spread  over 
the  wound  to  prevent  the  tube  from  adhering  to  it.  Not  more 
than  one  or  two  thicknesses  of  gauze  should  be  used  because  it 
will  become  clogged  with  the  wound  excretions  and  prevent  the 
solution  from  reaching  the  wound.  A  number  of  tube  A  may 
also  be  used  on  this  type  of  wound. 

In  all  eases  tubes  must  be  selected  in  which  the  perforations 
will  not  extend  beyond  the  edges  of  the  ivound. 

When  tube  D  is  used  the  glass  Y-connecting  tube  must  be 
affixed  before  it  is  put  into  place,  but  with  the  others  it  will  be 
found  more  satisfactory,  and  just  as  good  technic,  to  adjust 
their  connecting  tubes  after  the  patient  has  been  put  to  bed. 

c.  The  Gauze  and  Cotton  Dressings. — The  sterile  gauze  dress- 
ings are  next  applied,  and  over  them  the  cotton  pad,  non- 
absorbent  side  outward,  of  course.  In  nearly  all  cases  these 
pads  will  have  to  be  split  so  as  to  allow  the  rubber  delivery  tubes 
to  pass  outward  through  them  (Fig.  104)  rather  than  under 
them,  one  reason  for  this  being  that  by  this  means  the  tubes 
can  be  kept  in  place  better,  and  another  being  that  the  patient 
is  thus  protected  from  any  leakage  from  the  ends  of  the  tubes 
and  also  from  the  unpleasantness  of  contact  with  rubber.  The 
safety  pins  you  have  provided  will  come  into  service  at  this 
point. 

The  cotton  pads  must  never  be  omitted  because  they  serve 
two  important  purposes:  They  protect  the  bed  and  the  patient's 
clothing,  and  the  non-absorbent  layer  of  cotton  prevents  undue 
evaporation  of  the  solution.     In  this  connection  it  may  be  well 


THE  CARREL-DAKIN  TREATMENT 


339 


to  warn  the  nurse  against  covering  any  part  of  a  Carrel-Dakm 
dressing  with  rubber  sheeting  of  any  kind,  as  a  certain  amount 
of  evaporation  is  inevitable  and  the  re-condensation  that  would 
take  place  under  the  rubber  sheet  would  be  as  unwholesome 
and  uncomfortablct  in  this  case  as  every  nurse  knows  it  is  in 
all  others. 


340 


TEXTBOOK  OF  SURGICAL  NURSING 


The  dressings  arc  llicii,  of  coui'sc,  sccinrd  l)y  bandages,  or 
in  some  cases  l)y  tape  or  Avebbing-  straps  Avliicli  can  be  tied  in 
place.  Dressings  for  Carrel-Dakhi  cases  should  not  be  fastened 
quite  so  tightly  as  is  permissible  with  most  other  dressings, 
because  they  Avill  administer  the  solution  better  -when  loose,  and 
furthermore,  the  bandages  sometimes  shrink  a  little  when  they 
become  wet. 

2.  Adjustment  of  Instillation  Appliances. — Before  the  ar- 
rangement of  the  instillation  outfit  is  carried  further,  which- 
ever method  of  administration  is  to  be  used,  the  patient  must  he 
made  comfortable  and  the  bedding  adjusted  as  far  as  possible. 


Fig.  105. — Arrangement  of  the  Apparatus  for  the  Reservoir  Method 

OF  Instillation. 


The  chief  object  to  keep  in  mind  at  this  point  is  to  arrange  the 
patient  and  bedding,  in  relation  to  the  wound,  in  such  a  way  as 
to  make  possible  the  administration  of  the  Dakin  solution  with- 
out any  disturbance  or  discomfort  to  the  patient. 

Your  next  step  will  depend  upon  which  of  the  several  methods 


THE  CARREL-DAKIN  TREATMENT  341 

of  instillation  you  will  adopt.  The  details  of  these  methods  are 
as  follows : 

a.  For  the  Reservoir  Intermittent  Method. — This  is  the  most 
frequently  used  method,  and  after  it  is  installed,  and  as  long  as 
all  appliances  are  in  good  condition,  it  is  the  most  convenient 
one  (Fig.  105). 

The  solution  reservoir  has  been  elevated  above  the  level  of  the 
wound  about  18  inches  if  the  large  irrigator  is  used,  and  about 
3  feet  for  the  small  one ;  the  long  rubber  tube  has  been  securely 


Fig.  106. — Suggested  Ways  of  Bkanching  the  Main  Supply  Tube  So 
That  It  Can  Feed  the  Tubes  of  More  Than  One  Wound,  or  Widely 
Scattered  and  Variously  Grouped  Tubes  in  the  Same  Wound. 

attached  to  it;  the  metal  spring  stopcock  (A  of  Fig.  98)  has 
been  put  into  place  on  this  tube ;  the  reservoir  has  been  filled 
with  fresh  Dakin  solution  and  securely  covered;  and  now  the 
connection  will  be  made  to  the  wound  tubes. 

The  number  and  grouping  of  the  tubes  in  the  wound  will 
determine  which  of  the  glass  distributing  tubes  will  be  selected, 
and  the  important  thing  to  remember  here  is  to  make  all  con- 
nections so  that  the  tubes  will  be  allowed  to  remain  without 
tension  in  the  position  they  were  given  when  the  dressing  was 
done.  The  variety  of  glass  connecting  and  distributing  tubes 
enables  one  to  make  an  unlimited  number  of  combinations,  so 
that  any  number  of  ;wound  tubes  can  be  supplied  with  the  solu- 


342 


TEXTBOOK  OF  SURGICAL  NURSING 


tion  from  the  same  source  (Fig.  106).  A 
study  of  this  ilhistration  will  furnish 
enough  suggestions  to  cover  any  case, 

h.  For  the  Reservoir  Continuous 
Method. — When  this  method  is  adopted 
cMivcry  tuhe  C  (Fig.  95)  is  used  in 
the  wound.  Instead  of  the  spring  stop- 
cock on  the  main  supply  tuhe  the  screw 
one  (B  of  Fig.  98)  should  be  used,  and 
just  bclow^  this  the  tube  should  be  cut 
and  the  dropper  tuhe  (Fig.  100)  in- 
serted, as  indicated  in  Fig.  107.  Other- 
wise the  adjustment  is  the  same  as  that 
described  above  for  the  reservoir  inter- 
mittent method. 


c.  For  the  Syringe  Method. — If  the 
wound  tubes  are  easily  accessible  no 
further  adjustment  is  necessary,  for  the 
solution  can  be  injected  into  each  indi- 
vidual tube  directly  from  the  syringe. 
If  the  wound  is  so  situated,  however, 
that  this  is  inconvenient,  the  glass  con- 
necting and  distributing  tubes  and 
some  of  the  short  pieces  of  supply  tub- 
ing you  have  provided  can  be  arranged 
as  for  the  reservoir  method  so  as  to  be 
able  to  feed  the  solution  from  one  main 
tube  (Fig.  108). 

3.    Instillation    of    the    Solution.— 

The  standard  practice  is  to  administer 
the  solution  every  tivo  hours,  day  and 
night.  This  frequency  is  determined 
oJ'the''s7rew 'i^oP^K  by  the  fact  that  Dakin's  solution  is  very 
AND  THE  Glass  Dropper  unstable  and  loses  its  sterilizing  power 
Tube  on  the  Main  Supply    ,        ,  -,     r.    i  •  •    t      ^^^  i 

Tube  for  the  eeservoir    by  the  end  of  this  period.    The  mechan- 

CoNTiNuous   Method    of    ^^^  ^g  g^  adjusted,  as  you  are  now  pre- 

InSTILLATION.  o  :        ■    ^ 


THE  CARREL-DAKIN  TREATMENT  343 

pared  to  concede,  that,  with  average  care,  the  treatment  can  be 
given  without  any  disturbance  or  discomfort  to  the  patient,  and 
so,  it  is  just  as  easily  carried  out  during  the  night  as  in  the  day- 
time. This  is  a  very  merciful  feature  of  the  method  because 
this  is  one  treatment  which  is  never  interrupted.  The  impor- 
tance of  regularity  and  punctuality  in  the  instillation  is  one  of 
the  most  urgent  points  for  the  beginner  to  learn.  Another 
important  point  to  be  learned  early  is  to  pay  close  attention  to 
the  amount,  as  nearly  as  possible,  of  the  solution  which  is 
required  to  fully  bathe  each  individual  wound  and  then  reli- 
giously give  just  that  amount,  and  no  more  and  no  less.  If  too 
little  is  given  the  germs  in  the  parts  of  the  wound  unbathed 


Fig.  108. — Method  of  Connecting  Inaccessible  Wound  Tubes  to  a 
Single  Supply  Tube  for  the  Syringe  Method  of  Instillation. 

flourish  unhindered  and  indefinitely ;  if  too  much  is  given  it  may 
not  all  be  absorbed  before  the  next  instillation  and  the  old,  use- 
less solution  blocks  the  way  for  the  new.  Another  menace  of 
too  great  a  quantity  is  the  discomfort,  and  even  injury,  to  the 
patient  which  results  from  the  solution  being  spilled  over  healthy 
surroundings  of  the  wound  or  onto  the  bedding  and  causing 
irritation  of  the  patient's  skin.  In  some  instances  the  surgeon 
will,  when  he  has  finished  the  debridement,  estimate,  or  even 
measure,  the  correct  dosage  for  that  particular  wound  and 
prescribe  this  exact  amount  for  each  instillation.  As  you  can 
readily  see,  in  order  to  carry  out  this  provision  it  will  be  neces- 
sary that  either  the  syringe  method  of  administration  be  used, 
or  else,  that  you  be  equipped  with  the  graduated  glass  irrigator. 
Otherwise,  one  or  two  instillations  will  be  enough  to  teach  one 


344  TEXTBOOK  OF  SURGICAL  NURSING 

the  proper  quantity  for  a  given  "wound,  but  if  there  must  be 
doubt  at  any  time  it  is  better  to  err  on  the  side  of  too  much  than 
on  that  of  too  little.  Of  course,  as  the  wound  heals  a  smaller 
dosag-e  of  the  solution  will  be  necessary,  but  this  variation  will 
be  determined  from  time  to  time  when  the  wound  is  dressed. 

Details  of  the  actual  instillation  for  the  several  methods  are 
as  follows: 

a.  The  Reservoir  Intermittent  Method. — All  the  nurse  has 
to  do  to  make  the  instillation  by  this  means  is  to  open  the  stop- 
cock for  the  time  necessary  for  the  passage  of  the  amount  of  the 
solution  prescribed  or  estimated. 

The  two  great  errors  that  are  most  easily  committed  by  this 
method  are  to  allow  the  solution  to  ilow  too  suddenly  and  too 
forcefull,y,  and  to  give  too  large  a  dose.  Sudden  and  forceful 
instillations  are  painful  to  the  patient,  especially  if  the  solution 
is  cold.  The  objections  to  overdosage  have  been  mentioned 
above. 

Another  difficulty  is  to  determine  whether  or  not  all  the 
deli  very  tubes  are  functioning.  It  is  possible,  however,  to  get 
this  information  by  the  closest  scrutiny  of  the  glass  distributing 
tube  while  the  solution  is  flowing.  When  one  does  become 
blocked  it  may  sometimes  be  opened  by  disconnecting  it  at  tlie 
glass  distributing  tube  and  gently  forcing  some  of  the  Dakin's 
solution  into  it  with  a  syringe.  This  should  be  done  with  great 
care,  however. 

h.  The  Reservoir  Continuous  Method. — The  screw  stopcock 
is  so  adjusted  that  the  solution  drops  through  the  glass  dropper 
to  the  wound  at  the  proper  rate  to  keep  the  dressings  at  an  even 
degree  of  moisture.  The  actual  rate  will  depend,  of  course, 
upon  the  area  supplied  by  the  tube,  but  it  will  probably  be 
somewhere  between  5  and  10  drops  per  minute. 

This  was  the  method  originally  recommended  by  Dr.  Carrel, 
but  it  has  now  been  rather  laid  aside  in  favor  of  the  others. 

c.  The  Syringe  Method. — It  need  hardly  be  said  that  this 
method  consists  merely  of  injecting  the  Dakin  solution  into  the 


THE  CARREL-DAKIN  TREATMENT  345 

tubes  by  means  of  a  syringe.  This  should  be  done  slowly  and 
gently,  and,  as  remarked  before,  the  syringe  should  not  be  too 
large,  as  it  will  be  too  difficult  to  control. 

Two  features  of  the  syringe  method  make  it  a  close  competitor 
of  method  (a)  for  first  place.  The  first  is  the  fact  that  the 
dosage  can  he  more  easily  controlled;  and  the  second  is  that  one 
can  be  sure  that  each  individual  delivery  tiihe  is  always  free 
and  functioning.  Experience  with  the  syringe  system  has  dem- 
onstrated that  the  tubes  do  become  clogged  frequently  and  that 
considerable  effort  is  required  to  free  them. 

A  difficulty  which  arises  when  the  tubes  do  not  stand  upright, 
or  nearly  so,  in  the  wound,  is  that  the  solution  flows  out  again 
as  soon  as  the  syringe  is  withdrawn.  In  such  cases  the  rubber 
delivery  tubes  are  best  connected  up  to  one  supply  tube,  as 
described  for  the  reservoir  system,  and  this  tube  clamped  shut 
immediately  after  the  instillation  with  one  of  the  spring  clamps. 
Or,  in  some  cases,  if  the  delivery  tubes  are  long  enough,  this 
leakage  can  be  prevented  by  bringing  the  mouth  of  the  tube  up 
over  the  dressing  and  pinning  so  that  it  is  higher  than  the 
wound. 

III.  THE  BACTERIOLOGICAL  EXAMINATION  OF  THE 

WOUND 

After  the  lapse  of  a  day  or  two,  during  which  time  the  treat- 
ment has  been  going  on,  of  course,  a  system  of  microscopical 
examinations  of  the  wound  excretions  is  instituted. 

A  platinum  wire  loop  of  standard  size  is  used  to  take  up  the 
excretion  from  the  various  parts  of  the  wound  w^hich  are  believed 
to  be  most  infected;  this  material  is  then  spread  upon  a  slide 
and  put  through  the  usual  technical  process  for  preparing 
microscopical  slides.  Under  the  microscope  a  count  is  made  of 
the  numher  of  hacteria  in  a  given  field  and  the  result  is  recorded 
on  a  tracing  chart  similar  to  those  on  which  nurses  trace  tem- 
peratures (Fig.  109).  This  test  is  repeated  periodically,  usually 
every  second  day,  until  there  have  been  three  successive  exami- 
nations in  which  no  germs  were  seen,  when  the  wound  is  con- 
sidered sterile  and  ready  for  nature  to  heal. 


346 


TEXTBOOK  OF  SURGICAL  NURSING 


The  first  smear  or  two  may  not  show  much  decrease  in  the 
number  of  germs,  but  after  that  there  should  be  a  gradual 
decrease,  and  the  zero  mark  on  the  chart  is  reached  in  from  a 
few  days  to  several  weeks,  depending  upon  the  severity  of  the 
injury  and  upon  the  type  of  tissue  involved;  that  is,  whether 
it  is  the  soft  parts  of  the  body,  bone,  etc. 

If  the  expected  downward  course  of  the  count  does  not  take 
place  promptly  all  possible  causes  should  he  investigated,  and 


MONTH 

1 

OAY9 

Q 

-I 
U 
L. 

> 

a 
u 

0 

< 

bl 

> 
< 

O-O 

60 
40 
20 
10 

5 

1- 

1/2 
1/5 
l/io 
1/20 

^ 

^ 

Ml 

^ 

^ 

^ 

J 

_ 

-i 

^ 

^ 

_ 

_ 

_ 

_ 

_ 

^ 

Fig.  109. — Dr.  Carrel's  Bacteriological  Chart  for  a  Traced  Kecord 
OF  THE  Microscopical  Count  op  the  Bacteria  in  the  Smears  Taken 
from  the  Wound  During  the  Course  of  the  Carrel-Dakin  Treatment. 


the  trouble  will  usually  be  traced  to  one  or  more  of  the  following 
causes : 

1.  Incomplete  debridement. 

2.  Incorrectly  placed  delivery  tubes. 

3.  Insufficient  number  of  delivery  tubes. 

4.  Insufficient  amount  of  instillation. 

5.  Faulty  adjustment  of  dressings. 

6.  Flaw  in  technic  somewhere  along  the  line  from  dehride- 
ment  to  instillation. 

The  surgeon  or  the  pathologist  will  do  this  bacteriological 


THE  CARREL-DAKIN  TREATMENT  347 

part  of  the  technic,  though  there  may  be  cases  in  which  the 
nurse  will  be  called  upon  to  take  the  smear  from  the  wound. 
It  should  not  be  necessary  to  remind  the  nurse  that  the  strictest 
aseptic  technic  must  be  observed  in  this  act,  and  that  the  slide 
must  be  carefully  protected  from  contamination  until  delivered 
to  the  pathologist. 

The  smears  should  be  taken  at  the  same  hour  each  day;  not 
sooner  than  two  hours  after  an  instillation;  and  the  various 
operations  from  the  taking  of  the  smear  to  the  counting  of  the 
germs  should  be  clone  by  the  same  person  or  persons  throughout 
the  course  for  a  given  case,  so  as  to  eliminate  all  variations  due 
to  causes  outside  of  the  wound  itself. 

IV.  SUTURING  OF  THE  WOUND 

When  three  successive  smears  have  shown  no  germs  the  sur- 
geon then  sutures  the  wound,  which  should  heal  uneventfully. 
It  must  not  be  forgotten,  however,  that  this  sterilized  wound  is 
not  yet  safe,  but  that  it  may  be  reinfected  unless  the  rigid 
asepsis  is  maintained  until  healing  is  complete. 


One  case  has  now  been  carried  through  the  entire  course  of 
the  Carrel-Dakin  treatment  and  we  shall  proceed  to  learn  how 
to  treat  the  tubes  for  the  next  one. 

DISPOSAL  OF  USED  DELIVERY  TUBES 

If  in  good  condition  these  tubes  may  be  used  again,  but  the 
greatest  care  must  be  exercised  in  the  re-preparation  of  them. 

Immediately  upon  removal  from  the  wound  the  tubes  should 
be  stored  in  some  antiseptic  solution.  If  this  is  not  possible 
immediately  they  should  at  least  be  put  into  a  basin  of  saline 
solution  or  even  plain  water,  because  if  they  are  allowed  to 
become  dry  before  washing  it  will  often  be  very  difficult  to  get 
them  clean.  Any  antiseptic  solution  which  will  not  injure  rub- 
ber will  do,  such  as  lysol  or  carbolic.  Dakin's  solution  may  be 
used,  of  course,  but  unless  one's  supply  is  very  abundant  this 
is  more  extravagant  than  necessary. 


348  TEXTBOOK  OF  SURGICAL  NURSING 

In  any  case,  the  tubes  should  he  allowed  to  soak  for  several 
hours  in  the  antiseptic  solution  before  anyone  is  asked  to  handle 
them  for-  washing.  It  is  probably  true,  however,  that  these  tubes 
are  not  greatly  infected,  particularly  on  the  inside,  because  of 
the  fact  that  they  liave  constantly  been  in  contact  with  the  Dakiu 
solution  wliih^  in  the  wound. 

Nevertheless,  rubber  gloves  sJiould  be  worn  ivhen  washing 
them,  and  care  should  be  taken  not  to  splash  the  wash  water 
into  the  eyes,  mouth,  etc.  This  point  may  seem  an  unnecessary 
one  to  remind  nurses  of,  for  they  learn  early  in  their  work  to 
beware  of  such  accidents,  but  this  is  a  peculiar  case  because  of 
the  fact  that,  in  order  to  get  the  tubes  clean  on  the  inside,  it  is 
necessary  (for  they  are  tied  shut  at  one  end)  to  struggle  con- 
siderably with  them  while  holding  them  stretched  out  enough  to 
enlarge  the  perforations  sufficiently  to  allow  what  is  inside  to 
be  washed  out.  They  will  inevitably  snap  out  of  one's  fingers 
repeatedly  and  should  not  be  able  to  splash  anything  about  which 
is  not  reasonably  clean.  Clear  running  water  should  be  used 
first  in  the  washing,  and  then  soap  and  water.  The  use  of  a 
forceful  syringe  is  an  advantage  at  this  stage.  After  a  thorough 
rinsing  the  tubes  are  ready  for  the  final  boiling. 

THE  DAKIN  SOLUTION 

What  It  Is  Made  From. — Dakin's  solution  is  usually  made 
from  three  well-known  chemical  substances,  namely,  chloride  of 
lime,  carbonate  of  soda  (washing  soda),  and  bicarbonate  of  soda. 
This  sounds  as  though  it  should  be  a  very  simple  chemical  and  a 
very  easily  prepared  one,  but  as  we  shall  see  later,  when  we  get 
down  to  the  study  of  its  chemistry,  it  is  really  far  from  simple. 

AVhen  we  come  to  the  instructions  for  making  the  solution  we 
shall  give  a  process  in  which  the  chloride  of  lime  is  not  used, 
but  since  this  other  method  only  uses  another  means  of  obtain- 
ing the  all-important  chemical,  chlorine,  it  involves  no  vital 
difference. 

What  It  Is. — ^In  simple  terms  Dakin's  solution  is  a  0.45  to 
0.50  per  cent,  solution  of  sodium  hypochlorite.  Chlorine,  as  you 
may  know,  is  one  of  the  most  active  of  the  chemical  elements, 


THE  CARREL-DAKIN  TREATMENT  349 

especially  where  animal  and  vegetable  matter  are  involved,  and 
so,  while  this  makes  it  a  powerful  antiseptic,  it  must  also  be  re- 
membered that  it  v/ill  destroy,  in  time,  many  other  materials  with 
which  it  might  come  into  contact  while  you  are  using  it — your 
personal  clothing,  the  bedding,  etc.,  for  examples.  You  are  all 
familiar  with  Javelle  water,  or  bleaching  solution,  and  if  you  will 
learn  that  Dakin's  solution,  by  virtue  of  its  chlorine,  is  a  close 
relative  of  bleaching  solution  you  will  know  something  of  its 
action  in  this  respect. 

You  learned  in  the  beginning  of  this  chapter  what  "isotonic" 
means,  so,  now  we  can  reveal  to  you  the  very  important  fact  that 
Dakin's  solution  is  "isotonic"  with  the  Uood  serum,  and  that  is 
why  it  can  sterilize  wounds  as  no  other  solution  can. 

Before  this  time  you  may  have  advanced  so  far  in  your  expe- 
rience as  to  have  learned  about  Dichloramine-T  and  one  or  two 
other  recent  rivals  of  Dakin's  solution,  and  will  challenge  the 
above  claim  of  uniqueness  for  the  Dakin  solution;  but  these 
more  recent  antiseptics  have  merely  borrowed  the  Dakin  solu- 
tion secret,  the  chlorine,  and  used  it  in  another  form,  so  the 
claim  is  still  justified. 

In  the  exact  per  cent,  of  strength  given  above  Dakin's  solution 
is  at  the  same  time  very  active  antiseptically  and  only  very 
slightly  irritating. 

As  you  have  already  learned,  it  is  an  unstaMe  chemical, 
especially  when  exposed  to  the  chemical  action  of  light,  and  for 
this  reason  care  should  always  be  taken  to  keep  it  well  corked, 
away  from  the  light,  and  to  use  none  but  a  freshly  prepared 
solution.  In  well-regulated  hospitals  only  enough  for  one  day's 
use  is  made  at  a  time,  though  it  will  keep  well  for  perhaps  a 
week  or  two  if  very  carefully  protected. 

What  It  Does. — First  of  all,  Dakin's  solution  is  an  active 
germicide.  By  virtue  of  the  same  power  with  which  it  kills 
germs  so  effectively  Dakin's  solution  also  acts  upon  all  other 
organic  substances,  and  so  we  find  it  dissolving  Mood  clots,  pus, 
tissue  waste,  etc.,  in  the  wounds.  This  is  a  very  important  fact 
to  know  because  the  solution  of  a  Mood  clot  -may  entail  a  hemor- 
rhage, as  may  also  the  solution  of  waste  tissue.     This  should 


350  TEXTBOOK  OF  SURGICAL  NURSING 

bo  kept  ill  mind  at  all  times  wlieii  atliuinislering  the  treat- 
ment. 

Dakin's  solution  is  also  a  deodorant.  Perhaps  one  of  the 
first  points  that  a  nurse  will  note  about  her  first  "Dakinized" 
wound  is,  that  Avhere  otherwise  there  would  be  an  offensive 
odor  of  pus  there  is  only  the  fresh,  clean  odor  of  the  chlorine. 

Another  graceful  service  which  this  highly  accomi)lished  solu- 
tion gives  is  to  Icautify  the  ivound  into  a  healthful-appearing, 
rich,  red  color. 

How  It  Is  Made. — The  accurate  compoimding  of  the  Dakin 
solution  is  a  very  exact  and  technical  chemical  process,  and 
should  be  done  by  an  experienced  chemist ;  but  as  a  matter  of 
knowledge  and  reference  we  give  here  the  early  crude  process 
and  the  later  more  elaborate  one. 

Dakin's  Early  Process 

Ordinary  "water 10  litres 

Anhj'drous  carbonate  of  soda 140  g-rams 

or,  CrystalUzed  salt 400  grams 

Chloride  of  lime 200  grams 

Shake  the  mixture  well.  After  half  an  hour  siphon  off  the 
clear  liquid  and  filter  through  cotton.     Add  to  this  solution: 

Boric    acid     40  grams 

Daufresne's  Technic 

This  is  Dr.  Carrel's  own  description  of  the  process  as  pub- 
lished in  the  Journal  of  the  American  Medical  Association,  De- 
cember 9,  1916. 

Dakin's  solution  is  a  solution  of  sodium  hypochlorite  for  sur- 
gical use,  the  characteristics  of  which,  established  after  numer- 
ous tests  and  a  long  practical  experience,  are  as  follows: 

(a)  Complete  Absence  of  Caustic  Alkali. — The  absolute 
necessity  for  employing  in  the  treatment  of  wounds  a  solution 
free  from  alkali  hydroxide  excludes  the  commercial  Javelle 
water,  Labarraque's  solution  and  all  the  solutions  prepared  by 
any  other  procedure  than  the  following : 


THE  CARREL-DAKIN  TREATMENT  351 

(b)  Concentration. — The  concentration  of  sodium  hypo- 
cMorite  must  be  exactly  between  0.45  and  0.50  per  cent.  Below 
0.45  per  cent,  of  hypochlorite  the  solution  is  not  sufficiently  ac- 
tive; above  0.50  per  cent,  it  becomes  irritating. 

(c)  Chemicals  Required  for  the  Preparation. — Three  chem- 
ical substances  are  indispensable  to  Dakin  's  solution :  Chlori- 
nated lime,  anhydrous  sodium  carbonate,  and  sodium  bicar- 
bonate. Among  these  three  products  the  latter  two  are  of  a 
practically  adequate  constancy,  but  this  is  not  the  case  with  the 
first.  Its  content  in  active  chlorine  (decoloring  chlorine)  varies 
within  wide  limits,  and  it  is  absolutely  indispensable  to  titrate 
it  before  using  it. 

Titration  of  the  Chlorinated  Lime. — There  must  be  on  hand 
for  this  special  purpose : 

A  25  c.c.  buret  graduated  in  0.1  c.c. 
A  pipet  gauged  for  10  c.c. 

A  decinormal    solution    of     sodium    thiosulphite     (hypo- 
sulphite). 

This  decinormal  solution  of  sodium  thiosulphite  can  be  ob- 
tained in  the  market;  it  can  also  be  prepared  by  dissolving  25 
grams  of  pure  crystalline  sodium  thiosulphite  in  1  litre  of  dis- 
tilled water  and  verifying  by  the  decoloration  of  an  equal  vol- 
ume of  the  decinormal  solution  of  iodine  by  this  solution.  The 
iodine  is  prepared  by  dissolving  1.27  grams  iodine  and  5  grams 
potassium  iodide  in  100  c.c.  of  water. 

The  material  for  the  dosage  thus  provided,  a  sample  of  the 
provision  of  chlorinated  lime  on  hand  is  taken  up  either  with 
a  special  sound  or  in  small  quantities  from  the  mass  Avhich  then 
are  carefully  mixed. 

Weigh  out  20  grams  of  this  average  sample,  mix  it  as  com- 
pletely as  possible  with  1  litre  of  ordinary  w^ater,  and  leave  it 
in  contact  a  few  hours,  agitating  it  from  time  to  time.     Filter. 

Measure  exactly  with  a  gauged  pipet  10  c.c.  of  the  clear 
fluid ;  add  to  it  20  c.c.  of  a  1 :10  solution  of  potassium  iodide 
and  2  c.c.  of  acetic  or  hydrochloric  acid.  Drop,  a  drop  at  a 
time,  into  this  mixture  a  decinormal  solution  of  sodium  thio- 
sulphite until  decoloration  is  complete. 

The  number  of  cubic  centimetres  of  the  hypochlorite  solution 


352 


TEXTBOOK  OF  SURGICAL  NURSING 


required  for  complete  decoloration,  multiplied  by  1.775  gives 
the  freight  of  the  active  chlorine  contained  in  100  grams  of 
the  chlorinated  lime. 

This  figure  being  known,  it  is  applied  to  the  accompanying 
table,  which  will  give  the  quantities  of  chlorinated  lime,  of 
sodium  carbonate,  and  of  sodium  bicarbonate  which  are  to  be 
employed  to  prepare  10  litres  of  Dakin's  solution. 

Quantities  of  Ingredients  for  Ten  Litres  of  Daliin's  Solution 


Titer  of 

Chlorinated 

Anhydrous  Sodiimi 

Sodium  Bicar- 

Chlorinated 

Lime 

Carbonate 

bonate 

Lime 

Gm. 

Gm. 

Gm. 

20 

230 

115 

96 

21 

220 

110 

92 

22 

210 

105 

88 

23 

200 

100 

84 

24 

192 

96 

80 

25 

184 

92 

76 

26 

177 

89 

72 

27 

170 

85 

70 

28 

164 

82 

68 

29 

159 

80 

66 

30 

154 

77 

64 

31 

148 

74 

62 

32 

144 

72 

60 

33 

140 

70 

59 

34 

135 

68 

57 

35 

132 

66 

55 

36 

128 

64 

53 

37 

124 
1 

62 

52 

Example. — If  it  required  16.6  c.c.  of  the  decinormal  solution 
of  the  sodium  thiosulphite  for  complete  decoloration,  the  titer 
of  the  chlorinated  lime  in  active  chlorine  is: 
16.6  X  1.775  =  29.7  percent. 

The  quantities  to  be  employed  to  prepare  10  litres  of  the  solu- 
tion will  be  in  this  case : 

Chlorinated  lime    154  grams 

Dry  sodium  carbonate 77  grams 

Sodium  bicarbonate 62  fframs 


THE  CARREL-DAKIN  TREATMENT  353 

If  crystalline  sodium  carbonate  is  being  used,  then  instead 
of  the  80  grams  of  dry  carbonate  it  must  be  replaced  by : 

Crystalline  sodium  carbonate 220  grams 

Preparation  of  Dakin's  Solution. — To  prepare  ten  litres  of 
the  solution : 

1.  Weigh  exactly  the  quantities  of  chlorinated  lime,  sodium 
carbonate,  and  sodium  bicarbonate  which  have  been  determined 
in  the  course  of  the  preceding  trial. 

2.  Place  in  a  12-litre  jar  the  chlorinated  lime,  and  5  litres 
of  ordinary  water,  agitate  vigorously  for  a  few  minutes,  and 
leave  in  contact  for  from  6  to  12  hours,  over  night,  for  instance. 

3.  At  the  same  time  dissolve,  cold,  in  the  five  other  litres 
of  water,  the  sodium  carbonate  and  the  bicarbonate. 

4.  Pour  all  at  once  the  solution  of  the  sodium  salts  into 
the  jar  containing  the  maceration  of  the  chlorinated  lime,  agi- 
tate vigorously  for  a  few  moments,  and  leave  it  quiet  to  permit 
the  calcium  carbonate  to  settle  as  it  forms.  At  the  end  of  half 
an  hour  siphon  the  liquid  and  filter  it  through  double  paper  to 
obtain  an  entirely  limpid  product,  which  must  be  protected 
from  light. 

Light,  in  fact,  alters  quite  rapidly  solutions  of  hypochlorite, 
and  it  is  indispensable  to  protect  from  its  action  the  solutions 
which  are  to  be  preserved.  The  best  way  to  realize  these  con- 
ditions is  to  keep  the  finished  fluid  in  large  wicker-covered  demi- 
johns of  black  glass. 

Titration  of  Dakin's  Solution. — It  is  a  wise  precaution  to 
verify,  from  time  to  time,  the  titer  of  the  solution.  This  titra- 
tion utilizes  the  same  material  and  the  same  chemical  substances 
as  are  used  to  determine  the  active  chlorine  in  the  chlorinated 
lime: 

Measure  out  10  c.c.  of  the  solution,  add  20  c.c.  of  the  1 :10 
solution  of  potassium  iodide  and  2  c.c.  of  acetic  or  hydrochloric 
acid.  Drop,  a  drop  at  a  time,  into  this  mixture  a  decinormal 
solution  of  sodium  thiosulphite  until  decoloration  is  complete. 

The  number  of  cubic  centimetres  employed  multiplied  by 
0.03725  will  give  the  weight  of  the  sodium  hypochlorite  con- 
tained in  100  c.c.  of  the  solution. 

A  solution  is  correct  when,  under  the  conditions  given  above. 


354  TEXTBOOK  OF  SURGICAL  Nx^trsING 

from  12  to  13  c.c.   of  (kH-inornial  tliiosulpliitc  are   reciuired  to 
complete  the  decoloration : 

13  X  0.03725  =  0.485  per  eont.  of  XaOCl 

The  Test  for  the  Alkalinity  of  Dakin's  Solution. — It  is  easy 
to  differentiate  the  solution  obtained  by  tliis  procedure  from 
the  commercial  hypochlorites  aiid  from  Labarraque's  solution: 

Pour  into  a  glass  about  20  c.c.  of  the  fluid,  and  drop  on  the 
surface  a  few  centigrams  of  phenolphthalein  in  powdered  form. 
Dakin's  solution,  correctly  prepared,  gives  absolutely  no  change 
in  tint,  while  in  the  same  conditions  Javelle  water  and  La- 
barraque's fluid  give  an  intense  red  coloration  which  indicates 
in  the  latter  two  solutions  the  presence  of  free  caustic  sodium. 


Another  method  which  simplifies  the  manufacture  of  the 
Dakin  solution  if  the  requisite  apparatus  can  be  secured  is  sim- 
ply to  dissolve  the  sodium  carbonate  in  the  proper  amount  of 
water  and  then  pass  the  chlorine  gas  directly  into  this  solution 
from  cylinders  of  the  compressed  gas.  A  meter  is  used  to 
measure  the  gas  as  it  flows,  but  the  tests  used  in  the  above 
process  for  the  finished  product  must  be  made  in  this  case  also. 


CHAPTER  XX 


BANDAGING 


The  subject  of  bandaging  is  one  which  can  be  disposed  of 
with  a  few  arbitrary  demonstrations,  and  some  pupils  can  be 
trained  thus  into  dextrous  bandagers ;  but  on  the  whole,  time 
can  be  saved  and  more  intelligent  skill  attained  if  demonstra- 
tion and  practice  are  reserved  till  a  general  survey  of  the  field 
has  been  made  from  the  more  purely  theoretical  standpoint. 
It  may  be  true  that  the  art  of  bandaging  is  not  a  major  sub- 
ject, speaking  theoretically,  but  there  are  certain  real  principles 
involved  which  must  be  observed  in  all  bandaging  that  is 
worthy  of  the  name,  and  though  they  are  few  they  are  impor- 
tant enough  to  be  dignified  by  serious  classification  and  study 
as  a  foundation  for  practice.  Before  we  take  up  the  actual  prac- 
tice of  the  art  of  bandaging,  therefore,  let  us  prepare  ourselves 
to  do  it  as  intelligently  as  we  can. 

DEFINITIONS 

A  handage  may  be  defined  as  a  piece  of  flexible  material 
suitably  fashioned  for  application  about  something  as  a  cover- 
ing, a  reinforcement,  or  a  compressor. 

The  term  bandaging  will  then  mean  the  art  of  applying  the 
bandage  for  any  of  these  purposes. 

USES  OF  BANDAGES 

The  purposes  for  which  bandages  are  used  may  be  summed 
up  under  these  headings : 

1.  To  hold  dressings,  splints,  and  other  appliances  in  place. 

2.  For  support,  as  in  the  case  of  a  sprained  joint,  etc. 

3.  For  pressure,  as  in  the  ease  of  a  bleeding  vessel,  etc, 

355 


356 


TEXTBOOK  OF  SURGICAL  NURSING 


The  specific  uses  are  too  numei-ous  to  mention  here,  and  they 
will  be  readily  gathered  in  the  following  pages. 

FORMS  OF  BANDAGES 

Under  the  general  definition  the  bandage  may  be  of  a  great 
number  of  forms,  but  those  in  more  common  and  standard  use 
are:  (a)  The  Roller  Bandage,  (b)  The  Triangula)'  Bandage, 
(c)  The  Many-Tailed  Bandage. 


Fig.  110. — The  Eoller  Bandage, 

(a)  The  Roller  Bandage  (Fig.  110)  is  merely  the  bandage 
material  ^vhieh  has  been  cut  into  a  long,  narrow  strip  and 
rolled  up,  from  one  end  to  the  other,  into  a  compact  cylinder 
so  that  it  may  be  more  easily  and  quickly  handled  and  used. 

The  market  supplies  these  bandages  in  all  materials  and  sizes 
ready  for  use,  but  there  will  be  occasions  when  these  will  not  be 
available  and  every  student  should  learn  the  several  methods 
for  preparing  them.     There  are  numerous  hand  machines  for 


BANDAGING 


357 


Fig.  111. — Two  Methods  of  Eolling  a  Bandage  by  Hand. 


358  TEXTBOOK  OF  SURGICAL  NURSING 

rolling  bandages,  and  tlie  nurse  Avill  liave  access  to  these  in 
most  hospitals,  but  as  a  preparation  against  the  times  when  she 
■will  be  out  of  reach  of  machines  she  should  practice  one  or 
both  of  the  Junid  methods  illustrated  in  Fig.  111.  This  is 
really  a  simple  thing  to  do  and  the  only  points  to  bear  in  mind 
about  it  are  that  a  solidly  rolled  bandage  is  nuicli  more  satis- 
factorily applied  than  a  softly  rolled  one,  and  that  to  secure 
a  solidly  rolled  one  it  must  be  very  compactly  rolled  from  the 
very  beginning  because  the  whole  will  have  no  more  body  in 
the  end  than  its  core. 

The  roller  bandage  is  by  far  the  more  commonly  used  one, 
and  the  one  which  is  adaptable  to  the  greatest  variety  of  pur- 
poses. 

(b)  The  Triangular 
Bandage  (Fig.  112)  is 
simply  a  three-cornered 
piece  of  material  the  shape 
of  the  half  of  a  square 
which  has  been  cut  from  one 

Pig.  112. — The  Triangular  Bandage,     corner  to  the  diagonally  op- 
OR  Sling.  .,  i  •  i   i       t_ 

posite  one,  or  which  has  been 

folded  double  along  this  line.  Aside  from  one  or  two  uses  which 
will  be  encountered  later,  this  bandage  will  be  employed  only  as 
a  substitute  for  the  roller  bandage  in  emergency  cases,  as  it  is 
more  easily  and  quickly  improvised  than  the  roller  one. 

(c)  The  Many-Tailed  Bandage  (Fig.  113)  is  made  in  a 
number  of  slightly  varying  designs  but  consists  essentially 
either  of  a  single  oblong  piece  of  material  which  has  been 
split  at  each  end  into  two  or  more  tails  (A  and  B  of  the  illus- 
tration), or  of  a  combination  of  two  or  more  strips  whose  edges 
have  been  overlapped  and  stitched  together  in  the  middle,  leav- 
ing the  ends  free  (C  of  the  illustration).  The  particular  type 
C  is  commonly  known  as  the  Scultetus  bandage  or  binder.  The 
many-tailed  bandage  serves  few  purposes  for  which  the  roller 
bandage  will  not  be  preferred,  but  it  has  wide  application  and 
constitutes  a  very  serviceable  emergency  form  because  it  is 
simple  to  make  and  easy  to  apply. 


BANDAGING  359 


A 


Fig.  113. — Many-tailed  Bandages.  A  and  B,  the  simple  design  made 
by  splitting  the  ends  of  an  oblong  piece  of  material;  C,  the  Scultetus 
bandage  or  binder  made  from  strips  of  material  lapped  one  upon  the 
other  and  stitched  together   for   a  short  distance   in   the  middle. 


MATERIALS  USED  FOR  BANDAGES 

It  would  be  impossible  to  give  an  exhaustive  list  of  the  ma- 
terials from  which  bandages  are  made  because  there  is  scarcely 
any  limiting  requisite  except  that  of  flexibility.  However,  the 
more  or  less  standard  ones  for  the  three  forms  of  bandages  are 
as  follows: 

(a)     Boiler  Bandage 
Gauze 
Muslin 

Canton  flannel 
Woolen  flannel 


360  TEXTBOOK  OF  SURGICAL  NURSING 

"Elastic"  webbing    (-woven  cotton  bandage) 

Rubber 

Crinoline  impregnated  witli  stare-h — the  "starch  bandage" 

Crinoline  impregnated  with  plaster  of  Paris — the  ''plaster 

of  Paris  bandage" 
Crepe  paper 
Gauze  is  the  most  frequently  used  material.  Its  advantages 
are  that  it  is  light  in  weight,  cool,  and  so  flexible  that  it  is  easily- 
fitted  to  all  parts.  It  cannot  be  washed  or  used  a  second  time 
Avith  satisfaction  and  is  therefore  a  relatively  expensive  ma- 
terial. 

Muslin  is  very  suitable  where  greater  strength  is  needed,  as 
in  the  application  of  the  larger  splints,  in  the  arrest  of  hemor- 
rhage, and  in  other  cases  Avhere  more  pressure  is  required  than 
gauze  will  supply.  It  withstands  washing  and  repeated  usage. 
Canton  flannel,  because  of  its  combined  softness  to  the  touch 
and  its  strength,  is  often  used  where  pressure  is  necessary  over 
a  sensitive  part.  It  is  also  useful  as  padding  underneath  a 
plaster  or  starch  bandage. 

Woolen  flannel  is  used  chiefly  for  its  softness  of  texture.  It, 
too,  is  washable  and  can  be  used  repeatedly. 

'^Elastic"  wehhing  is  a  specially  woven  cotton  material  which 
furnishes  the  advantages  of  the  adaptability  and  a  large  part 
of  the  lightness  of  the  gauze,  a  measure  of  the  strength  of  the 
muslin,  the  softness  of  the  flannel,  and  the  elasticity  of  the 
rubber.  As  a  substitute  for  the  rubber  this  bandage  has  the 
very  desirable  superiority  of  being  highly  porous,  but  its 
strength  is  considerably  less. 

The  ruhher  bandage,  commonly  known  as  the  ''Esmarch,"  is 
made  of  gum  rubber.  It  is  used  as  a  pressure  or  constricting 
bandage  for  the  arrest  of  hemorrhage,  or  for  special  treatment 
(see  page  390). 

The  starch  bandage  is  merely  crinoline  which  lias  been  satu- 
rated with  a  boiled  solution  of  starch,  and  rolled  loosely  after 
it  has  become  dry.  It  is  softened  again  in  warm  water  for  the 
application,  and  when  it  has  dried  in  place  it  constitutes  a 
fairly  rigid  and  relatively  light  cast  or  splint.  It  will  be  used 
for  the  immobilization  of  fractured  or  otherwise  injured  parts. 


BANDAGING  361 

Plaster  of  Paris  bandages  are  made  of  crinoline  into  which  has 
been  rubbed  as  much  plaster  of  Paris  as  it  will  hold.  They  are 
applied  wet  and  in  numerous  layers,  and  when  they  have  dried 
they  make  a  very  rigid,  strong,  and  heavy  encasement  or  splint. 
They  are  used  where  complete  immobilization  of  a  part  is 
needed,  particularly  for   fractures. 

The  nurse  may  need  to  make  plaster  of  Paris  bandages  occa- 
sionally, and  to  do  so  she  will  proceed  thus :  Tear  the  crinoline 
the  desired  size  (see  under  "Sizes  of  Bandages,"  page  362),  and 
remove  all  ravelings;  pour  a  large  quantity  of  the  plaster  in 
a  heap  upon  a  smooth  table ;  lay  one  end  of  the  bandage  upon 
this,  brush  a  handful  of  plaster  over  it,  rub  firmly  and  smoothly 


Fig.    1 1  1.--.Mk-i-i[()d  op   jMaking  Plaster  ob'  Parts   Bandages.     Note  the 
large  quantity  of  plaster  in  use,  which  is  necessary  for  best  results. 

with  the  hand  two  or  three  times  and  then  roll  the  finished  por- 
tion carefully  and  loosely  (Fig.  114).  Proceed  thus,  rolling 
up  each  section  of  a  few  inches  as  fast  as  it  is  ready  and  han- 
dling very  carefully  so  as  not  to  undo  what  has  been  done.  Sub- 
stitutes for  the  hand,  such  as  a  wooden  spatula,  have  been  tried 
for  rubbing  in  the  plaster,  but  the  hand  is  the  best  instrument 
in  that  it  causes  less  friction  and  jarring  and  therefore  pro- 
duces a  more  smoothly  and  evenly  impregnated  bandage.  Use 
plenty  of  plaster  under  your  hand  as  you  rub,  brushing  off 
the  excess  immediately  before  rolling  the  finished  part.  Wrap 
each  bandage  securely  in  paper  as  soon  as  finished. 

Crepe  paper  makes  a  very  light  bandage,  and  as  it  does  not 
possess  much  strength  it  will  be  useful  only  where  very  slight 
protection  for  dressings  is  needed. 


362  TEXTBOOK  OP  SURGICAL  NURSING 

(b)     TriaiKjiihir  Bandage 

Muslin  is  the  usual  material  for  this  bandage,  but  anj'  similar 
material  ■will,  of  course,  serve  as  well. 

(c)     Many-Tailed  Bandage 

Muslin  and  Canton  flannel  will  be  used  for  this  bandage, 
the  choice  depending  upon  the  purpose  it  is  to  serve  and  the 
part  to  which  it  is  applied. 

SIZES  OF  BANDAGES 
(a)     The  Roller  Bandage 

The  length  of  the  factory-rolled  gauze  bandage  is  usually  10 
yards,  and  that  of  the  muslin  and  flannel  ones  5  yards.  These 
have  proved  to  be  the  most  serviceable  lengths  on  the  whole,  for 
these  materials,  the  greater  length  being  needed  in  the  gauze 
because  of  its  lighter  weight  and  inferior  strength  which  neces- 
sitate the  use  of  more  layers  of  it.  The  crinoline  for  the  starch 
and  plaster  of  Paris  bandages  may  be  of  any  length,  but  it  is 
wise  to  vary  the  length  with  the  width — that  is,  the  narrower 
ones  need  not  be  as  long  as  the  wider  ones. 

The  width  of  the  roller  bandage  will  depend  upon  the  part 
to  which  it  is  applied  and  will  vary  roughly  as  follows: 

Finger    %  to  1       inch 

Hand  and  arm li^  to  21/0  inches 

Foot  and  leg   IM2  to  3       inches 

Hip     3       to  4       inches 

Body  (chest  and  abdomen)    3       to  5       inches 

(b)     The   Triangular  Bandage 

This  bandage  will  vary  in  size  with  the  part  upon  which  it 
is  used  and  will  be  in  general  as  follows: 

Arm  (the  sling)   the  half  of  1  square  yard 

Hand the  quarter  of  the  sling 

Foot    the  half  of  the  sling 

Head the  half  of  the  sling 

Shoulder     the  half  of  1  square  yard 

Hip   the  half  of  1  square  yard 


BANDAGING  363 

(c)     The  Many -Tailed  Bandage 

It  will  not  be  very  helpful  to  prescribe  dimensions  for  this 
bandage  as  it  will  need  to  be  fitted  to  each  patient,  and  the  il- 
lustrations in  Fig.  145,  page  389,  will  guide  the  student  as  to 
the  proper  measurements  to  make. 

PRINCIPLES  OF  BANDAGING 

Before  we  undertake  to  apply  a  bandage  we  should  adopt 
as  our  fixed,  guiding  influences  these  three  principles  of  the 
art: 

1.  Evenness  of  Pressure 

2.  Durahility 

3.  Neatness 

These  principles  are  stated  in  the  order  of  their  importance, 
and  in  the  order  in  which  they  should  be  put  into  effect  by  the 
beginner,  but  one  may  not  call  herself  a  finished  practitioner 
until  she  is  able  to  observe  the  three  simultaneously.  They 
scarcely  need  elucidation,  but  a  few  important  details  pertain- 
ing to  each  of  them  which  the  student  should  be  reminded  of 
are  as  follows : 

1.  Evenness  of  Pressure. — Every  bandage  necessarily  ex- 
erts a  certain  amount  of  pressure  depending  upon  the  part  to 
which  it  is  applied  and  the  purpose  which  it  is  to  serve.  A  bony 
part,  such  as  the  skull,  for  instance,  will  need  and  endure,  in 
general,  more  pressure  than  a  yielding  part,  such  as  the  hand; 
and  a  bandage  applied  to  compress  a  bleeding  vessel  must,  of 
course,  exert  more  pressure  than  one  which  serves  the  mere 
purpose  of  keeping  a  dressing  in  place.  Much  practice  is  the 
only  means  of  acquiring  good  judgment  as  to  the  suitable 
amount  of  pressure  for  any  given  case,  and  this  must  always 
be  guided  by  an  intelligent  comprehension  of  the  object  of 
the  treatment  and  the  condition  of  the  part  bandag'ed,  and  by 
due  consideration  for  the  patient's  immediate  and  future  com- 
fort. 

"Whatever  the  tension  of  the  bandage,  however,  the  impor- 
tant point,  from  all  standpoints,   is  that  it  should  be  equal 


364  TEXTBOOK  OF  SURGICAL  NURSING 

throughout,  because  very  serious  results  may  follow  otherwise. 
In  the  first  plaee,  a  bandage  whieh  constricts  in  lines  here 
and  there  is  \tn-y  uncomfortahle.  This  objection  -svill  often  take 
care  of  itself,  however,  through  the  complaint  of  the  patient ; 
but  the  really  serious  damage  is  done  in  those  cases  where  the 
part  Avas  j)reviously  so  painful  throughout  or  so  subnormally 
sensitive  for  some  reason  that  the  patient  does  not  accuse  the 
bandage.  In  these  instances  the  unevenly-applied  bandage  may 
so  constrict  blood  vessels  and  compress  nerves  as  to  cause  gan- 
grene or  parahjais  in  the  part. 

Of  course,  a  bandaged  pai-t  is  always  kept  under  observation, 
but  the  best  precaution  against  accidents  from  unevenness  of 
pressure  is  plenty  of  diligent  practice  -with  the  bandage. 

2.  Durability. — The  importance  of  durability  in  an  applied 
bandage  is  so  self-evident  as  to  need  no  comment,  except,  per- 
haps, the  reminder  that  an  unstable  bandage  is  usually  a  very 
uncomfortahle  thing  to  wear. 

When  one  has  learned  the  first  principle  well  she  has  pro- 
gressed a  long  way  toward  the  secret  of  this  second  one.  That 
is,  a  bandage  which  is  evenly  applied,  within  the  limitations  of 
reasonably  good  pressure,  is  more  likelj^  to  stay  in  place  than 
the  uneven  one.  However,  the  problem  of  durability  involves 
much  more  than  this  and  it  is  perhaps  not  an  exaggeration  to 
say  that  excellence  is  harder  to  attain  under  this  principle  than 
under  either  of  the  other  two. 

Much  may  be  accomiDlished  as  to  durability  by  placing  the 
part  in  its  customary  position  or  in  the  desired  permanent  one 
before  applying  the  bandage,  because  muscular  motion  under- 
neath a  bandage  will  surely  disarrange  it  more  or  less. 

Finall}^,  faithfulness  to  the  method  customary  for  the  part  or 
purpose  will  be  of  great  importance  because  experience  is  re- 
sponsible for  the  particular  method  and  it  will  be  rare  that  the 
best  results  will  follow  any  considerable  departure  from  the 
advice  of  long  experience.  These  various  methods  will  be  taken 
up  a  few  pages  hence  and  the  student  wall  do  well  when  she 
reaches  them  to  accord  them  a  special  mark  of  respect  for  the 
sake  of  this  ])rineipl('  of  dural)ility. 

3.  Neatness. — This  last  principle  is  very  unproverbial  in 


BANDAGING  365 

that  it  is  also  the  least.  However,  though  they  do  not  rank  high 
as  objects  of  beauty,  most  of  the  standard  applied  bandages  do 
admit  of  some  artistic  merit  and  every  student  should  aim  to 
do  them  all  the  justice  possible  in  this  respect.  Neatness 
should  be  kept  in  mind  with  the  other  two  important  principles 
from  the  very  beginning,  because  with  practice  they  will  oper- 
ate very  well  in  unison,  and  if  careless  habits  are  once  formed, 
it  will  be  hard  to  inject  a  new  element  into  them. 

MODES  OF  APPLYING  THE  ROLLER  BANDAGE 

There  are  these  five  recognized  modes  of  applying  the  roller 
bandage  to  the  several  parts  of  the  body : 

1.  Circular 

2.  Spiral 

3.  Reverse 

4.  Figure-of-8 

5.  Recurrent 

Each  one  of  these  modes  has  its  reason  for  existence  in  some 
peculiar  adaptability  to  a  part,  in  a  special  suitability  for  some 
purpose,'  or  in  a  combination  of  the  two.  Very  few  applied 
bandages,  how^ever,  are  pure  examples  of  one  mode,  for  the 
complexity  of  design  in  the  human  framework  calls  for  a  com- 
pound of  tw^o  or  more  of  them  in  the  great  majority  of  cases. 
It  will  be  helpful  for  the  student,  nevertheless,  to  study  each 
of  these  five  elementary  designs  individually  because  she  will 
acquire  thereby  both  synthetical  and  analytical  power  in  the 
work  which  will  make  it  at  the  same  time  more  intelligible  and 
more  interesting  to  her.  Accordingly,  w^e  shall  pause  here  to 
present  each  of  the  five  modes  in  a  simple  detailed  example, 
and  if  the  student  will  take  this  discussion  seriously  she  wdll 
save  herself  much  floundering  when  she  comes,  a  few  pages 
hence,  to  the  necessarily  more  unorganized  presentation  of  band- 
aging as  applied  in  the  average  everyday  practice. 

First  of  all,  the  part  to  be  bandaged  is  arranged  in  the  posi- 
tion which  is  to  be  permanent  for  it ;  the  bandager  takes  a  posi- 
tion in  front  of  the  patient,  as  a  rule  (exceptions  will  be  dis- 
covered later)  ;  and  the  bandage  is  then  disposed  in  the  hands 


366 


TEXTBOOK  OF  SURGICAL  NURSING 


as  illustrated  in  Fig.  115 — that  is,  oiu'  hand  proiiaros  to  place 
and  keep  the  free  end  where  it  belongs  and  the  other  to  control 
the  unwinding  of  the  bandage  as  it  is  applied.  We  then  study 
the  five  different  modes  thus: 

-  1.  Circular  Mode. — The  head  is  one  of  the  subjects  for  this 
type  of  bandage,  and  so  with  both  liands  we  lay  the  bandage 
against  the  forehead  (Fig.  116),  a  small  portion  having  been 
unrolled  for  ease  in  properly  locating  it.  The  free  end  is  held 
against  the  temple  with  the  one  hand  while  with  the  other  the 
bandage  is  rolled  around  the  circumference  of  the  head  Avitli 


Fig.  115. — The  Way  to  Grasp  the  Roller  bandage  preparatory  to  Ap- 
plying It. 


even  and  firm  tension  till  it  reaches  the  free  end  when  it  is  con- 
tinued over  this  and  around  the  head  again  in  exactly  the 
same  track.  After  the  end  has  been  secured  the  hand  which 
held  it  will  be  released,  of  course,  to  assist  the  other  one  by 
carrying  the  roll  around  on  its  side  of  the  head.  AVhen  the 
roll  reaches  the  location  of  the  free  end  the  second  time  we 
have  a  circle  of  two  layers  of  bandage  around  the  head  (Fig. 
117),  and  have  thus  secured  by  friction  and  stress,  or,  in  other 
words,  have  "anchored/'  our  bandage;  and  at  the  same  time 
we  have  applied  the  amount  of  bandage  which  may  be  taken 
as  a  standard  foundation — that  is,  two  layers.  This  will  rarely 
ever  constitute  a  complete  piece  of  bandaging,  but  it  does  enter 


BANDAGING 


367 


Fig.  116. The  Way  to  Begin  the  Application  of  the  Eolleb  Bandage. 


Fig.   117.— The  Circular  Mode  op  Bandaging — the  usual  anchorage  for 
the  applied  roller  bandage. 

into  nearly  every  bandage  as  the  means  of  both  anchoring  it 
in  the  beginning  and  of  securing  it  at  the  end. 

2.     Spiral  Mode. — For  this   demonstration  we  shall  select 


368 


TEXTBOOK  OF  SURGICAL  NURSING 


the  upper  onn.  Grasp  the  bandage  as  before,  lay  it  upon  the 
arm  near  the  elbow,  and  apply  a  eireular  bandage — that  is, 
two  layers,  one  directly  upon  the  other,  entirely  around  the 
arm.  Then  begin  to  travel  upward  with  slow  spiral  turns  of 
the  bandage  (Fig.  118),  allowing  each  turn  to  cover  at  least 
one-third  of  the  width  of  the  previously-applied  one.  Keep  in 
mind,  as  you  do  tliis,  your  three  principles,  maintaining  the 
same  tension  on  your  bandage  throughout,  rolling  the  layers  on 
smoothly  and  at  a  stable  angle  (that  is,  not  so  great  an  angle 
that  they  will  have  a  tendency  to  creep  back),  and  make  it  as 

neat  as  you  can  by  keeping  the  edges 
of  every  two  layers  parallel  and  by 
covering  the  same  fraction  of  the 
width  of  the  previous  layer  every 
time.  Finished  with  two  or  more  of 
the  circular  turns,  this  will  make  a 
complete  design  which  is  applicable 
only  to  such  comparatively  parallel- 
sided  parts  as  some  upper  arms,  the 
fingers,    etc.,    or    to   similarly-shaped 

splints. 

3.  Reverse  Mode. — The  forearm 
is  a  suitable  part  upon  which  to 
demonstrate  this  mode  because  of  its 
cone-like  outline.  It  will  be  a  good 
plan  for  the  beginner  to  apply,  first 
of  all,  a  few  turns  of  the  spiral  bandage  to  this  part  in  order 
to  learn  at  once  why  it  will  not  answer  (Fig.  119).  She  will  see 
that  it  embodies  an  infraction  of  every  one  of  the  three  principles 
of  bandaging — that  is,  the  two  edges  of  the  bandage  exert 
unequal  degrees  of  pressure,  which  is  very  clear  from  the  fact 
that  one  of  them  is  entirely  free  of  tension  in  a  part  of  every 
turn;  it  will  not  stay  in  place,  as  its  appearance  very  clearly 
indicates  and  as  a  slight  pull  would  demonstrate;  and  it  cer- 
tainly does  not  look  neat.  AVe  can  correct  all  these  evils  very 
easily,  however,  in  this  way: 

Start  just  above  the  wrist  with  the  now  familiar  circular 
bandage;  then  begin  one  of  the  spiral  turns,  but  just  as  the 


Fig.    118. — The   Spiral 
Mode  of  Bandaging. 


BANDAGING  369 

lower  edge  of  the  bandage  shows  the  objectionable  slack,  which 
is  due  to  its  having  a  shorter  distance  to  cover  than  the  other, 
turn  the  roller  upside  down  (Fig.  120),  thus  making  a  twist  in 


Fig.  119. — The  Wrong  Mode  for  the  Part.     Note  the  loose  edge  of  each 
turn.     The  Spiral  Mode  will  fit  only  a  parallel-sided  part. 


the  bandage  which  uses  up  this  slack  and  allows  the  bandage 
to  lie  flat  for  the  remainder  of  the  turn,  when  the  same  prob- 
lem will  arise  and  it  will  be  solved  in  the  same  way  for  each 


Fig.  120. — The  Way  to  Make  a  Reverse.  The  roller  is  now  right  side 
up  because  one  reverse  has  already  been  made.  After  the  next  reverse  it 
will  be  upside  down  again. 

turn  until  the  part  is  covered.  In  the  act  of  twisting,  or  '^ re- 
versing," the  bandage,  special  care  is  required  to  avoid  stretch- 
ing it  so  tightly  that  it  will  be  drawn  into  wrinkles  instead  of 


370 


TEXTBOOK  OF  SURGICAL  NURSING 


into  one  flat  fold.  This  is  done  by  holding  the  applied  bandage 
down  Avith  one  hand  just  at  the  site  of  the  reverse  while  the 
free  part  is  allowed  to  slacken  slightly  for  the  moment  of  the 
reversal,  after  wliieh  the  usual  tension  is  resumed  for  the  next 
turn.  This  bandage  AA'ill  be  secured  at  the  end  with  the  usual 
circular  bandage. 

A  great  deal  of  practice  will  be  required  before  one  can  apply 
the  bandage  well  by  this  mode,  and  if  it  cannot  be  done  well 


A  ^ 

Fig.  121. — The  Figure-of-8  Mode  op  Bandaging.    A,  the  first  turns;  B,  the 
completed  bandage  of  the  ankle. 


some  other  mode  should  be  used  instead  for  there  are  too  many 
loopholes  in  it  for  offenses  against  all  of  the  three  principles  of 
bandaging.  It  is  a  very  suitable  method,  however,  for  tapering 
parts,  such  as  the  arm  and  leg,  and  if  one  wishes  to  become  a 
versatile  bandager  she  must  learn  it. 

4.  Figure-of-8  Mode. — The  ankle  furnishes  us  with  a  good 
subject  for  this  mode  of  bandaging.  Start,  as  usual,  with  the 
circular  bandage  as  your  anchorage,  placing  it  around  the  foot 
just  at  the  base  of  the  arch ;  then  pass  the  bandage  in  figure- 
of-8  style  thus:  Diagonally  across  the  instep  toward  the  base 
of  the  heel,  around  the  back  of  the  heel,  and  across  the  instep 


BANDAGING 


371 


again  in  the  other  diagonal  to  the  original  (drcular  bandage 
on  the  side  opposite  the  starting  point  of  the  first  diagonal  (A 
of  Fig.  121).  This  completes  one  figure-of-8  turn,  and  the 
bandage  is  continued  simply  by  repeating  this  maneuver  till  the 
part  is  covered,  lapping  each  turn  over  one-third  or  one-half  of 
the  width  of  the  preceding  one.     If  this  is  to  constitute  a  com- 


FiG.  122. — The  Recurrent  Mode  of  Bandaging.  The  patient  is  hold- 
ing the  reverses  in  place  at  the  back  of  the  head.  On  a  smaller  part,  such 
as  the  stump  of  a  limb,  the  bandager  can  control  the  entire  operation 
himself. 

plete  dressing  it  will  be  secured  by  the  circular  bandage  around 
the  ankle  (B  of  Fig.  121). 

Though  the  design  of  this  bandage  is  not  the  simplest  one 
to  learn,  aside  from  that  it  is  one  of  the  easiest  modes  with 
which  to  secure  good  results  under  all  of  the  three  principles. 
Durability  is  an  especially  prominent  feature  of  the  figure-of-8 
bandage,  and  its  appearance  can  be  made  to  compete  yery  fa- 
vorably with  that  of  any  of  the  other  modes. 

The  figure-of-8  design  has  a  very  wide  application,  being 
almost  the  only  suitable  one  for  the  joints  of  the  iocly,  particu- 
larly the  larger  ones,  such  as  the  ankle,  knee,  hip,  wrist,  elbow, 


372 


TEXTBOOK  OF  SURGICAL  NURSING 


and  shoulder;  and  it  is  also  applicable,  in  coiiibliidtiou  with  the 
reverse  mode,  in  various  other  parts  Avliich  will  be  indicated 
later. 

5.     Recurrent  Mode.— This  is  pei-hai)s  tlie  most  difiicult  mode 
to  learji  and  it  is  also  rather  awkward  to  ai)i)ly.  in  that  it  re- 
quires the  assistance  of  a  third  hand  wlien  api)lied  to  the  h(>ad, 
which  is  the  most  common  subject  for  it.     Often   the   patient 
himself  will  be  able  to  lend  this  helping  hand  but  if  he  can- 
not do  this  an  assistant  must  be  pro- 
vided.    As  it  Avill   probably  be  the 
only  available  part  for  practice,  we 
shall  select  the  head  for  our  subject. 
Pass  a  circular  bandage  around  the 
head,  as  described  in  ]\Iode  1,  stop- 
ping at  the  middle  of  the  forehead ; 
then    reverse    the    bandage   by   the 
same  maneuver  as  you  used  for  the 
reverse  Mode  (Fig.  120,  page  369), 
and  pass  the  roller  backward  across 
the  middle  of  the  head  and   down 
over  the  circular  turn  at  the  back, 
holding  the  fold  of  the  reverse  firm- 
ly in  place  with  the  thumb  of  the 
other  hand  meanwhile,  and  now  ask- 
ing the  patient  or  the   assistant  to 
place  his  hand  upon  the  intersection 
of  the  layers  on  the  other  side  (Fig. 
122).    Repeat  this  process,  back  and 
forth,  till  the  whole  head  is  covered,  working  from  the  middle 
toward  the  sides  alternately,  and  covering  one-half  of  the  pre- 
vious layer  each  time  (Fig.  123).     In  stationing  the  reverses  it 
will  be  found  possible  and  easiest  to  group  them  closely  together 
(each  immediately  on  top  of  the  previous  one)  in  the  middle  of 
either  side  rather  than  to  distribute  them  along  the  circular 
bandage,  as  they  can  be  more  easily  held  in  place  this  way  and 
they  will  usually  fit  the  part  better  thus.     AVhen  the  head  has 
been  entirely  covered  the  bandage  is  again  reversed  to  the  direc- 
tion of  the   original  circular  bandage   and  two  more   circular 


Fig.  123. — Completed  Ee- 
CURRENT  Bandage.  Note  that 
the  turns  all  lie  flat,  and  that 
they  converge  toward  the  mid- 
dle of  the  forehead,  wliieh 
means  that  the  reverses  are 
lying  directly  over  one  an- 
other, as  they  should  do. 


BANDAGING  373 

turns  are  passed  around  the  head  to  secure  the  ends  wliich  you 
and  your  assistant  have  been  holding. 

This  makes  a  comph^te  bandage  which  will  often  be  used  for 
the  stump  of  a  limb,  the  end  of  a  finger,  etc.,  as  well  as  for  the 
head. 

As  stated  above,  these  are  elementary  designs  which  will  be 
found  in  combinations  of  two  or  more  oftener  than  alone,  but 
we  shall  assume  that  the  student  has  practiced  them  as  advised, 
and  in  the  following  section  shall  build  up  the  numerous  com- 
plex designs  very  largely  in  terms  of  these  modes  without  again 
going  into  the  details  of  their  structure. 

THE  APPLICATION  OF  BANDAGES  TO  THE  VARIOUS  PARTS 

OF  THE  BODY 

(a)   The  Roller  Bandage 
Hand  and  Arm 

It  will  be  an  unusual  case  in  which  a  bandage  will  be  applied 
to  the  fingers,  the  hand,  and  the  entire  arm  at  the  same  time; 
but  the  student's  best  plan  is  to  combine  these  parts  in  one  les- 
son and  it  will  then  be  an  easy  matter  for  her  to  make  the 
subtractions  appropriate  for  any  given  case. 

Either  the  spiral  or  the  combination  of  the  figure-of-8  and 
reverse  modes  will  be  found  suitable  for  the  fingers,  with  the 
introduction  of  the  recurrent  mode  if  the  ends  of  the  fingers  are 
to  be  covered.  As  a  rule,  however,  a  finger  bandage  will  not 
be  durable  unless  it  is  connected  with  the  wrist  by  means  of  a 
figure-of-8  and  a  circular  bandage  (Fig.  124),  introduced  after 
every  second  or  third  spiral  turn.  Each  finger  may,  of  course, 
be  bandaged  in  this  way  separately,  but  in  everyday  practice 
it  will  be  found  that  w^hen  two  or  more  fingers  need  bandag- 
ing they  will  usually  be  combined  in  one  dressing  and  bandaged 
together,  in  wdiich  case  the  method  for  a  single  finger  will  apply. 
In  cases  where  all  the  fingers  are  involved  they  will  usually  be 
combined  in  a  single  large  dressing  and  the  suitable  mode  of 
bandaging  them  will  then  be  the  recurrent  one   (see  Fig.  122, 


374 


TEXTBOOK  OF  SURGICAL  NURSING 


page  371).    The  finger  bandage  may  be  anchored  either  around 
the  wrist  or  tlie  end  of  the  finger. 

The  thumb  presents  a  somewhat  different  ease  from  the  fin- 
gers in  that  it  is  nearly  always  bandaged  with  what  is  termed 
the  "spica"  bandage  (Fig.  125).     This  spica  involves  nothing 


Fig.  124. — Spiral  Bandage  of  the  Finger  Anchored  to  the  Wrist  with 
a  flgure-of-8  and  a  circular  turn. 

new  as  to  mode,  for  it  is  a  pure  figure-of-8,  but  it  so  happens 
that  in  the  complete  design  the  layers  present  the  appearance  of 
the  spikes  in  a  head  of  barley,  and  therefore  the  bandage  has 
been  given  the  distinctive  name  ' '  spica. ' '  Though  the  ,  term 
has  its  origin  in  the  mere  appearance  of  the  completed  bandage, 


Fig.  125. — The  Thumb  Spica. 

"spica"  always  carries  with  it  the  meaning  of  a  joint  bandage 
because  the  figure-of-8  takes  on  this  appearance  in  all  cases  of 
its  application  to  a  joint  ^vhich  connects  an  appendage  to  its 
trunk.  The  application  of  a  thumb  spica  will  present  no  new 
problem  to  the  student,  and  we  have  emphasized  it  here  only 
for  the  sake  of  introducing  the  term  which  wall  arise  in  several 
other  cases  later. 

Whether  or  not  the  fingers  and  the  thumb  are  involved,  our 


BANDAGING 


375 


method  of  procedure  for  the  hand  and  arm  will  be  this  (Fig. 
126)  :  Begin  about  the  palm  with  the  circular  bandage,  then 
a  spiral  or  two  if  necessary,  and  proceed  with  the  figure-of-8 
over  the  back  of  the  hand  and  the  wrist,  around  the  wrist  with 


Fig.  126. — Complete  Bandage  for  the  Hand  and  Arm. 


Fig.  127. — Reverse  Figure-of-8  Bandage.    A,  front  view  showing  the  figure- 
of-8  turn;  B,  rear  view  showing  the  reverse  turn. 

the  circular,  upward  over  the  cylindrical  part  of  the  forearm 
with  the  spiral,  and  thence  with  the  reverse  over  the  conical 
part  to  the  elbow.  The  elbow  (in  a  slightly  flexed  position)  is 
then  covered,  directly  over  the  joint,  with  two  or  three  circular 


376  TEXTBOOK  OF  SURGICAL  NURSING 

turns,  several  figure-of-8  turns  (enough  to  cover  it  securely) 
are  passed  over  this  and  about  the  joint,  -working  upward  and 
downward  from  the  joint  alternately.  The  upper  arm  is  then 
covered  with  either  th(>  spiral  or  the  reverse,  depending  upon 
whether  it  is  of  a  general  eylindrieal  shape  or  a  conical  one. 

On  the  shafts  of  the  arm  a  combination  of  the  figure-of-8  and 
the  reverse  modes  are  very  suitable,  the  figure-of-8  being  used 
as  the  theme  and  the  reverse  being  introduced  only  when  needed 
to  keep  the  bandage  lying  fiat  and  to  equalize  the  tension  of 
the  edges,  which  will  usually  be  every  second  turn  (Fig.  127). 
In  this  ease  the  cross  of  the  figure-of-8  turn  is  made  on  the  top 


Fig.  128. — Method  foe  Securing  Better  Anchorage  of  a  Bandage 
ON  A  Tapering  Part.  The  long  spii'al  turns  provide  friction  for  the  re- 
mainder of  the  bandage  and  also  stabilize  the  wrist  portion. 

of  the  arm  (A  of  Fig.  127)  and  the  reverse  on  the  back  (B  of 
Fig.  127).  This  bandage  is  very  much  preferred  to  any  other 
by  some  persons  because  of  its  superior  durahility. 

Another  variation  sometimes  employed  for  securing  durabil- 
ity in  a  bandage  of  a  forearm  which  is  extremely  conical  in 
shape  is  to  run  a  lo]ig  spiral  turn  (just  after  completing  the 
wrist  section)  from  the  wrist  to  the  elbow,  one  or  two  circular 
turns  around  the  arm  just  below  the  elbow,  and  then  the  long 
spiral  back  again  (Fig.  128).  This  gives  the  forearm  bandage 
the  advantage  of  a  little  more  friction  for  keeping  it  in  place 
on  the  sloping  part,  as  it  will  not  tend  to  slip  so  much  on  these 
turns  of  gauze  as  it  would  on  the  bare  skin ;  and  these  layers 
have  been  made  very  secure  by  the  turns  at  the  elbow. 

Foot  and  Leg 

The  toes  may  be  bandaged  separately,  like  the  fingers ;  and 
when  the  figure-of-8  extension  is  necessary  to  keep  it  in  place 


BANDAGING  377 

the  ball  of  the  foot  will  usually  answer  as  the  wrist  does  for 
the  fingers.  Also,  as  in  the  case  of  the  fingers,  when  several 
or  all  of  the  toes  are  involved  they  will  usually  be  dressed  to- 
gether and  the  bandage  will  be  the  recurrent  one. 

Under  Mode  4,  page  370,  the  ankle  bandage  has  been  pre- 
sented but  the  heel  was  not  included  as  it  involves  one  or  two 
special  considerations,  and  in  practice  it  is  not  covered  in  a 
foot  bandage  unless  there  is  a  particular  reason  for  doing  so. 
When  the  heel  is  involved  the  principles  of  the  elbow  bandage 
may  be  applied  to  it — that  is,  after  the  circular  turns  have  been 
applied  around  the  arch  of  the  foot  a  long  spiral  turn  of  the 


A 

Fig.  129. — Heel  Bandage.     A,  regular  circular  and  figure-of-8  method;  B, 
variation  necessary  for  a  prominent  heel — an  interlocked  figure-of-8. 

bandage  will  carry  it  smoothly  to  the  heel,  a  circular  bandage  is 
applied  around  the  heel  and  the  instep,  and  the  figure-of-8 
ankle  bandage  is  then  applied  as  in  the  case  of  the  elbow  (A 
of  Fig.  129). 

In  cases  where  the  heel  is  unusually  prominent  it  will  be  im- 
possible to  cover  it  smoothly  with  the  figure-of-8  bandage.  This 
difficulty  may  be  overcome  by  modifying  the  design  for  several 
turns  as  illustrated  in  B  of  Fig.  129.  An  analysis  of  these 
turns  will  show  that  they  constitute  merely  an  interlocked 
figure-of-8  passing  crosswise  of  the  ankle. 

In  general  principles  the  foot  and  leg  handage,  as  a  whole, 
is  exactly  like  that  for  the  hand  and  arm.  Disregarding  the 
toes,  we  start  around  the  arch  of  the  foot  with  the  circular 


378  TEXTBOOK  OF  SURGICAL  NURSING 

turns,  and  one  or  two  spirals  if  needed.  Then  cover  the  heel 
as  described  in  the  preceding  paragraphs.  This  will  entail  the 
fignre-of-8  of  tlie  ankle  which  was  described  under  Mode  4, 
page  370.     The  details  for  the  remainder  of  the  leg  will  then 


Fig.  130. — Complete  Bandage  for  the  Foot  and  Leg. 

correspond  exactly  wdth  those  given  for  the  arm,  including  the 
several  variations  pointed  out  there  (Fig.  130). 

The  knee-joint  bandage,  of  course,  wall  be  upside  down  from 
the  standpoint  of  the  bandager  as  compared  with  the  elbow, 
but  this  will  not  cause  any  noteworthy  confusion. 

The  Eye 

The  eye  bandage  becomes  a  very  simple  one  if  we  conceive  of 
it  as  being  constructed,  as  it  really  is,  entirely  from  the  ele- 
mentary circular  bandage.  Accordingly,  let  us  imagine  our 
standard  circular  bandage  to  be  rigid,  like  a  barrel  hoop,  and 
fit  it  thus  into  the  several  positions  of  the  layers  in  the  eye 


BANDAGING 


379 


bandage.  First  of  all,  we  place  it  around  the  top  of  the  head 
as  we  did  the  circular  bandage  in  the  demonstration  of  Mode 
No.  1 ;  this  is  our  foundation,  or  anchorage.  Then  we  imagine 
this  circle  on  a  pivot  near  the  base  of  the  nose  and  swing  it 
down  over  the  eye  we  are  to  bandage  till  it  reaches  the  neck  just 
below  the  ear  on  that  side,  and  meanwhile,  on  the  opposite  side 
just  over  the  other  ear,  it  will  have  risen  somewhat  above  our 
foundation  circle.     The  two  circles  will  now  cross  each  other 


Fig.  131. — The  Eye  Bandage.    A,  the  first  two  circular  turns  in  place;  B, 
the  completed  bandage  for  one  eye. 


on  the  forehead  and  on  the  back  of  the  head  (A  of  Fig.  131). 
Then  we  swing  our  circle  again  but  only  far  enough  this  time 
to  cover  one-half  or  one-third  of  the  width  of  the  parts  of  the 
other  layers  which  lie  below  the  one  ear  and  above  the  other. 
In  other  words,  this  layer  lies  the  width  of  the  lap  nearer  each 
ear  than  the  preceding  one  and  crosses  it  on  the  forehead  and 
on  the  back  of  the  head  at  the  sites  of  its  intersections  with  the 
horizontal  turn.  This  maneuver  is  repeated  until  we  have 
enough  angling  layers  (usually  two  or  three)  to  cover  the  eye 
well,  and  then  we  swing  our  circle  back  again  into  the  first 


380 


TEXTBOOK  OF  SURGICAL  NURSING 


Fig.  132. — Double  Eye  Bandage. 


position  and  apply  ono  or  two 
of  the  horizontal  tnrns  to  an- 
chor the  Avhole  (B  of  Pig. 
1-'51).  On  some  heads  it  may 
l)c  necessary  to  anchor  each 
angling-  circle  willi  the  hori- 
zontal one,  bnt  this  will  mean 
merely  swinging  the  circle  al- 
ternately from  one  position  to 
the  other. 

The  flexible  bandage  will 
not  i^erform  with  all  the  me- 
chanical exactitude  of  the 
rigid  hoop,  of  course,  and  the 
changes  in  plane  will  have  to 
be  made  with  gradual  sweeps, 
but  these  will  be  easily  man- 
aged if  the  student  has  her 
picture  of  the  hoop  structure 
clearly  in  mind. 

To  handage  hoth  eyes  all 
one  needs  to  do  is  to  alternate 
the  angling  turns  between  the 
two  eyes,  and  as  a  rule  one 
anchoring  turn  should  be  ap- 
plied for  each  pair  of  angling 
ones.  The  whole  is,  of  course, 
anchored  finally  with  one  or 
two  of  the  horizontal  turns 
(Fig.  132). 


Fig.     133. — The     Ear     Bandage. 
Note  that  it  is  merely  tlie  eye  bandage  The   Ear 

design    slipped    about    one-quarter    of 
the    way    around   the   head,    and   that 

more   turns   are   required   for   the   ear  rp^^^  g^^,  bandage,  for  either 

region  than  were  needed  for  the  eye.  . 

one  or  both  ears,  will  corre- 
spond to  that  for  the  eyes  in  all  detail  except  that  more  turns 
will  be  necessary  as  a  rule  (Fig.  133).  In  bandaging  one  ear  it 
is  sometimes  difficult  to  avoid  covering  the  opposite  one  also,  but 


BANDAGING 


381 


by  careful   planniiif?  this   (lifficulty   can   practically  always  be 
overcome. 

The  Face  and  Jaw 


The  Barton  bandage  of  the  jaw  will  be  used  in  case  of  frac- 
ture where  immobilization  is  desired.  When  analyzed  this  may 
be  called  a  compound  figure-of-8  bandage,  for  it  is  composed 
of  two  figure-of-8 's  which  have  one  loop  in  common — that  is, 
the  loop  which  envelops  the  crown  of  the  head  makes  a  figure- 


FiG.  134. — The  Barton  Bandage.  A,  method  of  anchoring;  B,  the 
complete  design.  As  this  is  usually  a  pressure  bandage  two  or  more  layers 
will  usually  lie  necessary.  The  fastening  of  this  bandage  is  not  shown  as 
it  will  be  best  placed  on  the  head  or  face  turn  on  the  other  side. 

of-8  with  either  one  of  the  two  adjoining  ones.  To  apply  this 
bandage,  begin  by  laying  the  end  of  the  bandage  diagonally 
across  the  top  of  the  head,  pass  downward  across  one  cheek,  un- 
derneath the  chin,  upward  over  the  other  cheek,  across  the 
head  in  the  other  diagonal  (A  of  Fig.  134),  downward  and 
around  the  back  of  the  head,  forward  around  the  front  of  the 
chin,  thence  to  the  back  of  the  head,  and  then  upward  to  the 
starting  point  at  the  top  of  the  head.  This  is  the  complete  de- 
sign of  the  bandage  (B  of  Fig.  134),  but  as  it  is  usually  applied 
for  pressure  upon  the  jaw  one  or  two  layers  more  will  be  added. 


382  TEXTBOOK  OF  SURGICAL  NURSING 

This  bandage  "will  usually  be  applied  under  ronsidevable  tension. 

The  illustrations   (Fig.  135)   show  hru   «v///.s-  of  applying  a 

haudage  to  the  cheek,  temple,  or  chin.     They  need  no  special 

explanation  except  that  they  are  started  like  the  Barton  band- 


3 

Fig.  135. — Two  Methods  of  Bandaging  the  Cheek,  Temple,  or  Chin. 
A,  a  simple  figure-of-8  which  will  fit  a  head  with  a  prominent  crown;  B, 
method  necessary  when  the  crown  of  the  head  is  flatter,  the  'turns  about 
the  forehead  alternating  with  the  others  and  binding  them  iu  place.  Band- 
age A  is  fastened  on  the  other  side  of  the  head. 

age.  Since  heads  vary  so  much  in  shape  a  trial  must  always 
be  made  of  the  first  turn  of  these  bandages  to  make  sure  that 
it  is  stably  stationed.  A  variation  forward  or  backward,  on 
the  top  of  the  head,  of  the  starting  point,  will  always  enable 
one  to  find  the  proper  balance. 

The  Head 

The  appropriate  bandage  for  the  head  is  the  recurrent  one 
which  we  described  under  Mode  No.  5  (Figs.  122  and  123, 
pages  371  and  372). 

A  more  convenient  way  to  apply  the  head  bandage,  however, 
is  with  tivo  roller  handages,  the  ends  of  which  have  been  care- 
fully pinned  or  sewed  together  (Fig.  136).  For  this  we  pro- 
ceed thus:  Lay  the  bandages  against  the  middle  of  the  fore- 
head, and  then  hold  one  stationary  while  you  apply  the  an- 


BANDAGING 


383 


choring  circular  bandage  about  the  head  with  the  other.  Then 
pass  the  bandage  which  has  been  idle  across  the  top  of  the 
head  to  the  circular  turn  at  the  back,  roll  the  other  bandage 
across  this    (Fig.  137),   and  then  continue  carrying  the   one 


'K 


Fig.  136. — Double  Eolleb  Bandage  for  the  Application  of  the  Recur- 
rent Bandage. 

bandage  back  and  forth  over  the  top  of  the  head  and  binding 
it  down  at  each  end  by  the  circular  turns  of  the  other. 

The  whole  head  may,  of  course,  need  to  be  covered  thus,  but 
the  student  should  form  the  habit  (which  does  not  seem  nat- 


FiG.  137. — The  Way  to  Use  the  Double  Roller  Bandage. 

ural  for  beginners)  of  putting  on  only  as  much  of  the  head 
bandage  as  is  necessary  to  keep  the  dressing  in  place,  as  it  is 
very  easily  discontinued  at  any  point. 

This  recurrent  bandage,  especially  when  applied  to  the  head, 
is  usually  designated  as  the  "  capeline"  bandage,  because  of  its 


384 


TEXTBOOK  OF  SURGICAL  NURSING 


likeness  to  an  iroji  skull  cap  which  was  worn  by  soldiers  in  the 
Middle  Ages. 

The  Shoulder  and  Axilla 

The  '^spica"  is  the  bandage  most  frecinently  used  for  the 
shoulder  (Fig.  138).  Like  the  thumb  spiea,  of  course,  it  is 
merely  a  figure-of-8  design,  and  needs  no  comment  except,  per- 
haps, to  point  out  that  the  application  of  it  is  begun  about  the 
arm,  and  that  a  few  spiral  or  reverse  turns  should  be  made 
around  the  arm  for  secure  anchorage  before  beginning  the 
spica  proper. 

AVhen  there  is  a  dressing  in  the  axilla  to  be  covered  the  shoul- 


FiG.  138. — The  Spica  Bandage  of  the  Shoulder. 

der  spica  may  be  varied  by  alternating  turns  around  the  chest 
with  the  figure-of-8  turns  (Fig.  139). 

The  Velpeau  bandage  will  be  used  to  immobilize  the  shoulder 
in  such  cases  as  fracture  of  the  clavicle  or  scapula  or  disloca- 
tion of  the  shoulder.  Place  the  arm  of  the  injured  side  across 
the  chest  so  that  the  hand  lies  Avell  up  toward  the  other  shoulder. 
Start  the  bandage  by  placing  the  end  over  the  scapula  of  the 
sound  side,  carry  the  roller  forward  over  tlie  injured  shoulder, 
angling  doAvnward  and  underneath  the  humerus,  and  thence 
forward  over  the  anterior  chest  and  around  to  the  starting 
point  (A  of  Fig.  140).     Repeat  thi^  turn  once  for  security  and 


BANDAGING  385 

strength,  then  make  a  circular  turn  around  the  chest  and  over 
the  arm  just  at  the  elbow,  and  then  complete  the  bandage  by 
alternating  these  two  turns  till  the  whole  arm  has  been  cov- 
ered (B  of  Fig.  140). 


Fig.  139. — The  Shoulder  Spica  Bandage  Varied  to  Cover  the  Axillary 

Eegion. 


Fig.  140. — The  Velpeau  BANDAGE.r  A,  the  first  turns,  two  or  more 
layers  being  necessary,  as  a  rule,  in  the  turn  about  the  humerus;  B,  the 
completed  Velpeau. 

The  Breast 

This  bandage  is  another  figure-of-8,  one  loop  of  the  figure 
passing  horizontally  about  the  chest  and  the  other  diagonally 


386 


TEXTBOOK  OF  SURGICAL  NURSING 


between  the  affected  side  and  the  opposite  slionlder   (A  of  Fig. 
141). 

Start  underneath  the  arm  of  the  affected  side  and  anchor  the 
bandage  with  two  circular  turns  about  the  chest  just  beneath 


A  3 

Fig.  141. — The  Breast  Bandage.    A,  the  way  to  start  the  bandage;  B,  the 

complete   design. 

the  breast,  passing  the  roller  across  the  anterior  chest  first  and 
then  around  the  back — that  is,  when  the  right  breast  is  to  be 
bandaged  the  end  of  the  bandage  is  placed  under  the  right  arm 

and  the  roller  is  carried  across 
the  anterior  chest  to  the  left 
arm ;  and  for  the  left  breast  the 
direction  is  reversed.  The  an- 
chorage completed,  the  first 
diagonal  turn  is  started  directly 
underneath  the  breast,  and  is 
carried  well  over  on  the  oppo- 
site shoulder,  thence  angling 
downward  across  the  back  and 
around  to  the  starting  point. 
These  alternate  horizontal  and 
diagonal  turns  are  then  re- 
peated till  the  whole  breast  is  covered  (B  of  Fig.  141). 

To  bandage  lioth  hreasts  at  the  same  time,  start  as  for  one. 
Apply  the  first  diagonal  turn,  start  the  next  horizontal  turn  but 
carry  it  only  as  far  as  the  opposite  side  and  then  instead  of 
completing  it  carry  it  diagonally  upward  across  the  back  to  the 


Fig 


142. — The    Double    Bkeast 
Bandage. 


BANDAGING 


387 


other  shoulder,  and  tlunice  diagonally  downward  across  the  an- 
terior chest  and  underneath  the  otliei-  breast.  Tlicii  apply  a 
complete  circular  turn  and  extend  it  around  to  the  starting 
point  under  the  first  breast.  Continue  the  bandage  by  alter- 
nating the  diagonal  maneuvers  with  the  horizontal  one  till  the 
breasts  are  covered  (Fig.  142). 


Hip  Spica 

There  is  no  essential  difference  between  this  bandage  and  the 
spica  of  the  thumb.  The  hip  spica  is  sometimes  applied  with- 
out the  circular  turns  about  the  waist  (A  of  Fig.  143),  but  the 
alternation  of  the  circular  turn  with  each  figure-of-8    (B   of 


A  3  c 

Fig.  143. — The  Hip  Spica  Bandage.  A,  without  the  circular  turn  about 
the  waist;  B,  with  the  circular  turn  alternating  with  each  figure-of-8;  C, 
the  double  spica  applied  with  a  single  bandage. 

Fig.  143)  makes  a  more  durable  bandage  and  one  which  will 
be  more  comfortable  for  most  patients.  Any  part  of  the  hip 
region  may  be  covered  with  this  bandage  by  simply  placing 
the  spica  directly  over  the  wound.  This  bandage  may  be 
started  around  either  the  waist  or  the  leg. 


388 


TEXTBOOK  OP  SURGICAL  NURSING 


A  double  liip  s\nri\  is  very  rcadilx  xipplicd  with  diic  biindajxe 
by  simply  altcni.-it  in<_;-  tiic  liuurc-dl'-S's  hclwccu  the  sides  and 
inserting  circular  liiriis  ahoiil  Hie  waisl,  between  them  eaeh 
time  (C  of  Fig.  14:5).  Tlus  bandage  may  be  started  around 
either  the  waist  oi-  one  leg. 

For  the  apiilieation  of  these  bandages  it  will  be  necessary  to 
elevate  the  patient's  hips  on  some  such  rest  as  that  shown  in 
B  of  Fig.  43,  page  220. 


(b)   The  Triangular  Bandage 

As  remarked   previously,   the   triangular   form   of   bandage, 
with  one  or  two  exceptions  (chiefly  the  sling),  is  an  emergency 


Fig.  144. — Various  Applications  of  the  Triangular  Bandage. 

one  and  will  be  used  only  in  the  absence  of  the  roller  bandage. 
Emergencies,  however,  are  very  important  and  the  nurse  should, 
therefore,  not  consider  her  bandaging  education  complete  till 
she  has  become  adept  with  the  triangular  bandage.     Parts  to 


BANDAGING 


389 


which  this  bandage  may  be  applied  are  the  arm  (sling),  hand, 
head,  foot,  shoulder,  hip,  etc.,  and  the  illustrations  (Fig.  144) 
will  give  the  student  all  the  suggestions  she  will  need  for  the 
several  cases. 

The   three   principles   of  bandaging   are,   of   course,   as    ap- 
plicable to  this  form  of  bandage  as  to  the  roller  one. 


(c)   The  Many -Tailed  Bandages 

The  student's  first  concern  as  to  these  bandages  is  to  make 
them  of  the  proper  size  because  they  must  fit  well  if  they  are 


Fig.  145. — Various  Applications  of  the  Many-tailed  Bandages. 

to  be  faithful  to  our  three  bandaging  principles.  Parts  to 
which  the  several  types  are  applicable  are  the  head,  chin,  breast, 
abdomen,  arm,  leg,  etc.,  and  the  illustrations  (Fig.  145)  will 
show  the  variations  suitable  to  these  different  parts. 


390  TEXTBOOK  OF  SURGICAL  NURSING 

MISCELLANEOUS  SPECIAL  BANDAGES 

The  plaster  of  Paris  handagc  is  a  roller  bandage,  but  as  it  is 
applied  wet  and  eviMitnally  liecomes  very  rigid  its  application 
involves  a  few  iioints  wliicli  dift'erentiate  it  from  the  average 
roller  bandage.  First  of  all,  the  plaster  is  never  placed  directly 
upon  the  skin,  a  substantial  ]iadding  of  cotton,  Canton  flannel, 
or  stockinet,  etc.,  always  being  used  underneath  it.  Tlie  nurse 
^\ill  rarely  ever  apply  this  bandage  herself  but  she  will  assist 
with  it  and  her  part  will  doubtless  be  the  soaking  of  it.  This 
she  will  do  by  standing  it  on  end  in  a  basin  of  sufficient  warm 
water  or  weak  salt  solution  to  cover  it.  A  very  few  moments 
wall  suffice  for  saturating  it,  the  cessation  of  the  bubbling  Avhich 
always  follows  immersion  indicating  that  it  is  ready  for  use. 
Since  you  have  probably  made  the  bandage  yourself  you  will 
know  how  insecure  the  plaster  is  wdthin  it  and  will  therefore 
be  very  cautious  about  the  removal  of  it  from  the  water.  It 
must  be  squeezed  just  enough  so  that  the  water  will  no  longer 
drip  from  it — no  more  and  no  less — for  if  too  wet  the  dripping 
water  will  carry  the  plaster  away  with  it  and  will  unnecessarily 
wet  the  padding,  and  if  too  dry  it  will  become  hard  before  it 
can  be  applied.  Your  method,  therefore,  wall  be  to  encircle 
the  bandage  very  cautiously  with  a  hand  at  either  end,  com- 
press the  ends  gently  at  the  same  time,  lift  it  out  of  the  water, 
and  simultaneously  extend  your  pressure  over  the  remaining 
surface  just  sufficiently  to  stop  the  dripping — but  do  not  twist 
it.  Practice  is  required  to  do  this  well  and  without  wastage 
of  the  bandages,  for  it  must  be  done  quickly  as  well  as  care- 
fully. As  light  w^ood  splints  are  sometimes  used  to  reinforce 
this  bandage  they  will  be  part  of  the  nurse's  preparation,  as 
wdll  also  a  small  amount  of  dry  plaster  which  is  sometimes  used 
for  finishing  the  surface  of  it. 

For  the  application  of  the  starch  bandage  the  nurse's  prepara- 
tion will  be  similar  to  that  for  the  plaster,  but  the  bandages 
will  not  require  the  extreme  care  in  handling  and  they  may 
be  more  nearly  freed  of  the  water. 

The  Esmarch  bandage  is  sometimes  applied  for  the  purpose 
of  reducing  the  venous  circulation  of  a  congested  part  and 


BANDAGING  391 

thereby  increasing  its  arterial  supply  and  the  accompanying 
local  nourishment.  This  constitutes  a  special  treatment  known 
as  the  "Bier's"  treatment.  It  will,  therefore,  never  be  admin- 
istered except  by  special  order,  but  it  belongs  to  the  subject  of 
bandaging  and  there  are  several  points  about  it  which  the  nurse 
should  learn. 

The  treatment  is  usually  administered  to  some  inflamed  part 
of  the  extremities,  and  the  general  rule  of  applying  the  bandage 
from,  below  upward  will  hold  in  this  case.  The  mode  of  appli- 
cation will  be  the  spiral  one ;  the  bandage  will  be  applied  above 
the  inflamed  part ;  and  as  the  object  of  the  bandage  will  be  to 
restrict  the  venous  circulation  and  not  the  arterial,  it  must  not 
be  applied  too  tightly.  The  frequency  and  duration  of  this 
treatment  will  be  prescribed,  and  while  it  is  in  operation  the 
nursing  attention  must  be  faithful.  The  parts  below  the  band- 
age should  retain  their  normal  temperature;  there  should  be 
no  accompanying  pain;  the  pulse  in  the  part  should  not  be  al- 
tered; but  a  moderate  amount  of  swelling  and  edema,  and  a 
bluish-red  color,  should  be  expected.  As  a  rule,  the  part  will  be 
elevated  after  the  bandage  has  been  removed  to  hasten  the 
reduction  of  the  edema,  but  the  nurse  will  be  guided  by  in- 
structions from  the  surgeon  as  to  this. 

Varicose  veins  of  the  leg  are  sometimes  treated  with  a  pres- 
sure handage.  The  material  to  be  used  for  this  bandage  will 
usually  be  prescribed,  and  it  may  be  any  one  of  those  we  have 
already  discussed.  The  elastic  materials,  however,  will  prob- 
ably be  given  preference,  though  where  elasticity  is  desired  it 
may  be  secured  in  some  degree  with  an  inelastic  bandage  by 
first  covering  the  part  with  a  thin  layer  of  non-absorbent  cot- 
ton. The  importance  of  this  bandage  from  our  present  stand- 
point lies  in  the  requirements  that  it  be  very  smoothly  and 
evenly  applied,  that  its  tension  be  sufficient  to  support  the  en- 
larged veins  without  obliterating  them,  and  that  it  be  applied 
as  follows :  Elevate  the  foot  somewhat  before  applying  the 
bandage  so  that  the  veins  will  not  be  unnecessarily  engorged ; 
start  the  bandage  near  the  toes ;  and  use  the  spiral  form  as  much 
as  possible  throughout,  departing  from  it  only  sufficiently  to 
secure  even  pressure  over  the  more  irregularly-shaped  parts. 


392  TEXTBOOK  OF  SFKOTCAL  NURSING 

A  pressure  bandage  is  sometimes  applied  to  the  extremities, 
particularly  the  legs,  in  ease  of  shock  to  reduce  the  circulation 
in  them  to  some  degree  and  therebj^  to  conserve  the  heart's 
energy  somewhat.  A  generous  layer  of  non-absorbent  cotton 
should  ahvays  be  used  under  this  bandage  because,  while  it  fur- 
nishes the  usually  desired  elasticity  it  also  conserves  the  body 
heat  whieh  is  vitallj^  important  in  such  cases. 

Many  of  the  bandages  described  in  the  practical  discussion 
above  might  properly  be  classified  here  also  as  "special"  band- 
ages— for  examples,  the  ankle  bandage  in  a  case  of  sprain,  the 
Velpeau,  the  Barton,  some  of  the  spicas,  and  sometimes  the 
breast  bandage — ^but  as  they  are  tluis  distinguished  merely  by 
their  greater  tension  tliey  merit  only  mention  in  this  connection. 

THE  FASTENING  OF  THE  BANDAGE 

(a)   The  Boiler  Bandage 

First  of  all,  the  site  selected  for  the  securing  of  the  end  of 
the  bandage  should  be  remote  enough  from  the  wound  to  avoid 
causing  pain  to  the  patient  by  the  manipulation  necessary.  If 
not  inconsistent  with  this  point,  an  accessible  place  should  be 
chosen  for  evident  reasons.  And  of  not  the  least  importance 
is  the  point  that  all  fastenings  that  protrude,  such  as  knots  and 
safety  pins,  should  be  so  placed  that  the  patient  will  not  have 
the  discomfort  of  resting  upon  them. 

There  are  only  about  four  good  methods  for  fastening  the 
bandage  and  they  have  their  special  adaptations  and  limitations 
as  follows : 

1.  Safety  Pin.— This  fastener  (A  of  Fig.  146)  will  apply 
to  most  bandages  and  it  is  a  very  satisfactory  one  because  it 
can  be  passed  through  all  the  underlying  layers  and  so  bind 
them  all  securely  together.  It  may  sometimes  be  objection- 
able, however,  for  children  in  places  where  they  can  reach  it 
and  open  it,  or  where  they  might  injure  themselves  upon  it. 
Likewise,  irrational  patients  are  liable  to  interfere  with  this 
fastener. 

2.  Adhesive  Plaster. — This  is  an  unobtrusive  and  neat 
fastener  (B  of  Fig.  146)  but  it  is  not  as  secure  as  the  safety 


BANDAGING 


393 


Fig.  146. — Methods  of  Fastening  the  Eoller  Bandage.  A,  the  cor- 
ners of  the  end  have  been  turned  under  so  as  to  make  a  stronger  and  neater 
finish,  and  a  safety  pin  has  been  passed  through  it  and  as  many  of  the 
underlying  layers  as  possible;  B,  the  corners  of  the  end  have  been  neatly 
turned  under  and  a  strip  of  adhesive  plaster  binds  it  to  the  layer  under- 
neath; C,  the  end  of  the  bandage  has  been  split  lengthwise  far  enough  to 
make  two  tails  long  enough  to  be  tied  around  the  part,  a  knot  being  tied 
at  the  bottom  of  the  slit  to  prevent  further  tearing;  D,  the  corners  of  the 
end  are  turned  under  and  a  few  stitches  of  thread  taken  between  it  and  the 
immediately  underlying  layer. 


pin  and  will  not,  therefore,  answer  for  some  pressure  bandages. 
Also,  it  cannot  be  used  for  a  bandage  over  a  wet  dressing  nor 
in  any  other  case  where  the  bandage  is  likely  to  become  wet, 
as  in  the  instanee  of  the  Carrel-Dakin  treatment. 


394  TEXTBOOK  OF  SURGICAL  NURSING 

3.  Tying. — This  is  a  rough-and-ready  method  (C  of  Fig. 
146)  whit'h  can  always  be  resorted  to  in  the  absence  of  other 
means.  To  fasten  the  bandage  by  this  method,  tear  or  cut  it 
down  tlie  middle  of  the  end,  tie  a  knot  at  the  bottom  of  the 
slit  to  prevent  further  tearing,  and  then  tie  these  strips  around 
the  part.  The  student  should  learn  this  method  but  she  should 
immediately  store  it  away  for  emergency  use  only,  as  it  is  al- 
most never  comfortable  to  the  patient  because  of  the  fact  that 
if  it  is  tight  enough  to  hold  the  bandage  in  place  it  will  cause 
a  line  of  stricture. 

The  Esmarch  'bandage  is  an  exception  to  this  case  in  that 
tying  is  about  the  only  suitable  method  for  it.  The  rubber 
■will  not,  of  course,  be  split  to  make  the  strings,  for  tapes  are 
usually  cemented  to  one  end  for  the  purpose.  If  these  are 
lacking,  however,  a  few  turns  of  a  gauze  bandage,  a  piece  of 
tape,  or  anything  similar  may  be  fastened  about  the  terminus 
of  the  Esmarch.  The  above-mentioned  objection  to  tying  does 
not  enter  into  this  case  because  the  rubber  is  rigid  enough  to 
dissipate  the  objectionable  pressure  of  the  string. 

4.  Sewing. — This  method  (D  of  Fig.  146)  is  applicable 
W'here  greater  strength  is  needed,  or  in  the  case  of  children  or 
irrational  patients.  It  goes  without  saying,  of  course,  that 
great  caution  is  necessary  in  sewing  a  bandage  on  a  patient. 

(b)   The  Triangular  Bandage 

The  safety  pin,  tying  of  the  corners,  or  both  (see  Fig.  144, 
page  388),  will  cover  all  cases  for  this  bandage. 

(c)   The  Many -Tailed  Bandages 

Tying  of  the  ends  or  safety  pins  will  answer  for  the  head  and 
chin  bandages,  but  for  the  other  parts  safety  pins  are  all  but 
indispensable  (see  Fig.  145,  page  389). 

MISCELLANEOUS  BANDAGING  RULES 

1.  Never  bandage  two  surfaces  of  shin  together — separate 
them  with  gauze  or  cotton,  preferably  non-absorbent  cotton. 
There  is  always  a  certain  amount  of  moisture  present  on  the 


BANDAGING  395 

surface  of  the  skin  and  if  this  is  confined  it  will  accumulate, 
and  in  addition  to  being  uncomfortable  it  may  seriously  chafe 
the  parts  in  time.  The  non-absorbent  cotton  keeps  these  sur- 
faces apart  and  allows  evaporation  of  the  moisture,  whereas 
absorbent  cotton  or  gauze  absorbs  and  retains  it.  This  applies 
particularly  to  the  fingers,  toes,  axilla,  and  the  arm  and  (;hest 
in  the  case  of  the  Velpeau  bandage. 

2.  In  all  cases  where  surgical  necessity  does  not  contravene, 
parts  should  he  handaged  in  their  accustomed  position.  This 
applies  with  special  emphasis  to  the  ears,  which  should  always 
have  sufficient  padding  behind  them  to  prevent  their  being 
held  more  closely  to  the  head  than  is  natural  for  them.  Band- 
ages of  the  neck,  axilla,  the  hand  and  fingers,  and  the  toes, 
also  call  for  special  consideration  in  this  respect. 

3.  In  bandaging  the  hand  and  foot  leave  the  fingers  and  toes 
exposed  if  possible  so  that  they  may  be  watched  as  guides  to 
the  condition  of  the  circulation  of  the  limb.  Coldness,  blue- 
ness,  and  swelling  of  the  fingers  or  toes,  or  of  any  part  below 
a  bandage,  are  signs  that  it  is  too  tight  at  some  point.  This 
accident  is  very  largely  precluded  by  attention  to  pressure  in 
the  application  of  the  bandage,  but  it  must  not  be  forgotten 
that  parts  under  even  the  most  expertly  applied  bandage  may 
swell  later  from  causes  entirely  unrelated  to  the  bandage  itself. 
In  the  cases  of  the  arm  or  leg  the  pulse,  if  accessible,  at  the 
radius  or  the  dorsum  of  the  foot  will,  of  course,  be  a  valuable 
guide  to  the  state  of  the  arterial  circulation. 

4.  Do  not  apply  a  wet  landage  because  it  will  probably 
shrink  in  drying  and  become  too  tight.  The  plaster  of  Paris 
and  starch  bandages  are,  of  course,  exceptions,  but  they  are 
always  applied  with  this  in  mind,  and  a  thick  padding  of 
stockinet,  cotton,  or  Canton  flannel  is  usually  provided  under- 
neath them  to  guard  against  this  danger. 

5.  When  applying  a  bandage  over  a  wet  dressing,  or  over  a 
Carrel-Dakin  dressing  which  will  eventually  become  wet,  re- 
member this  probability  of  shrinkage  and  apply  it  correspond- 
ingly loosely. 

6.  If  necessary  to  bandage  a  dressing  under  a  splint,  remem- 
ber to  do  it  loosely  because,  even  though  you  may  be  able  to  note 


396  TEXTIU)()K  OF  SlKiiK'AL  Xl'KSIXO 

the  condition  of  the  part,  it  Avill  be  very  ineonvenient  to  correct 
undue  tightness  in  this  case,  and  durability  is  not  important 
here  since  the  splint  and  its  bandage  Mill  give  the  additional 
security  ■  needed. 

7.  In  placing  the  reverses  of  the  reverse  bandage,  see  that 
they  are  not  over  bony  or  prominent  parts,  such  as  the  shin 
or  radius,  for  they  may  become  very  jiainful  because  of  the 
inicvcn  surface  they  i-reate.  The  line  of  these  reverses  is  best 
l)lacc(l  on  ihc  (iii1>i(lc  of  the  leg  and  arm. 

8.  Always  apply  the  roller  handage  from  below  upward, 
particularly  when  exerting  special  pressure,  because  when  put 
on  in  the  opposite  dir(H'tioii  it  allows  the  veins,  which  are  even- 
tually' to  be  underneath  it,  to  become  engorged  with  blood  which 
is  thus  imprisoned  and  may  later  be  the  cause  of  much  dis- 
comfort and  even  more  far-reaching  trouble.  Likewise,  the 
Seultetus  bandage  should  be  fastened  from  below^  upward. 

9.  Make  it  a  rule  in  applying  the  roller  bandage  to  the  ex- 
tremities to  start  hy  rolling  it  outward  rather  than  inward — 
that  is,  to  bandage  a  right  arm  or  leg  (assuming  that  you  are 
face-to-face  with  your  patient),  hold  the  roller  in  your  left 
hand  and  start  by  rolling  it  toward  your  left  side ;  to  bandage 
a  left  arm  or  leg,  then,  you  will  hold  the  bandage  in  your  right 
hand  and  start  it  toAvard  your  right.  A  test  application  will 
show  you  that  observance  of  this  rule  will  give  you  greater  free- 
dom and  ease  in  the  adjustment  of  the  reverses  and  the  fig- 
ure-of-8  's. 

THE  REMOVAL  OF  ROLLER  BANDAGES 

Gauze  and  paper  bandages  are  rarely  ever  used  more  than  once 
and  they  are  therefore  usually  cut  away.  If  one  is  equipped 
with  the  special  bandage  scissors  (Fig.  147),  the  operation  is 
very  simple  as  the  blunt  point  can  be  passed  underneath  the 
bandage  with  perfect  safety,  provided,  of  course,  that  the 
region  of  the  Avound  is  entirely  avoided,  as  it  should  be  in  any 
case. 

The  washable  and  rubber  bandages  will  simply  be  uuAvound, 
and  a  little  practice  will  enable  one  to  roll  them  together  loosely 


BANDAGING 


397 


as  fast  as  they  ai-e  uiiwouiid.  DcxtcrJIy  in  this  is  really  a 
valuable  acquisition  because  it  saves  much  time  and  avoids  an- 
noyance to  the  patient  and  confusion  to  the  bandager. 

For  tile  removal  of  plaster  of  Paris  'bandages  one  needs  a 


Fig.  147. — Bandage  Scissors.  The  one  longer  point  is  blunt  and  smooth 
and  is  designed  to  be  passed  underneath  a  bandage  immediately  on  the 
surface  of  the  patient's  body  without  danger  of  injury  during  the  process 
of  cutting  off  the  bandage — a  procedure  which  is  never  safe  with  an  ordi- 
nary pair  of  scissors. 

strong  knife  or  saw  and  a  pair  of  strong  bandage  scissors. 
There  are  special  instruments  (Fig.  148)  made  for  this  pur- 
pose and  they  will  usually  be  provided  in  hospitals.  The  oper- 
ation  consists  merely  in   cutting   directly  through  the   entire 


Fig.  148. 


-Instruments  for  the  Eemoval  of  Plaster  of  Paris  Bandages 
— Saw,  Knife,  and  Heavy  Bandage  Scissors. 


length  of  the  shell  in  a  sufficient  number  of  places  to  enable 
one  to  lift  the  cast  away  with  as  little  disturbance  as  pos- 
sible to  the  patient.  The  lines  chosen  must  be  accessible,  of 
course;  if  possible  they  should  be  remote  from  the  wound   (if 


398  TEXTBOOK  OF  SURGICAL  NURSING 

there  is  one)  ;  and  to  save  labor  one  should  selert  the  shortest 
lines  thai  will  answer  the  jMirpose.  Some  labor  may  be  saved 
in  the  sawiuy-  proeess  by  Avetting  the  plaster  immediately  ahead 
of  the  instrument  with  a  few  drops  of  hydrogen  peroxide, 
acetic  acid,  or  bichloride  solution.  These  solutions  have  a 
slightly  solvent  power  over  the  plaster,  but  a  little  plain  water 
answers  the  purpose  very  well  also.  Care  should  be  taken  not 
to  use  enough  of  these  solutions  to  wet  bandages  or  dressings 
underneath,  and  it  should  also  be  remembered  that  the  bichloride 
will  be  very  unkind  to  the  metal  instruments  if  exposed  to 
them  too  long.  The  precaution  should  always  be  taken  of  dis- 
carding the  knife  or  saw  in  favor  of  the  scissors  before  this 
bandage  is  entirely  severed  to  escape  the  danger  of  cutting 
the  patient.  Sometimes  this  labor  will  be  obviated  by  the  sur- 
geon who  Avill  cut  the  plaster  just  after  applying  it  and  while 
it  is  still  soft.  In  this  case  the  cast  will  be  bound  together  by 
a  strong  bandage  and  its  removal  will  then  be  a  simple  matter. 
Starch  bandages  can  usually  be  cut  with  strong  bandage  scis; 
sors,  though  if  they  are  thick  the  plaster  knife  or  saw  may  be 
needed. 


Finally,  practice  is  your  great  highway  to  success  in  the  art 
of  bandaging.  We  may  seem  to  have  led  you  through  more, 
devious  byways  than  necessary  to  bring  you  to  it,  but  we  be- 
lieve this  is  a  case  of  the  longest  way  around  being  the  short- 
est way  home. 


CHAPTER  XXI 
OPERATIONS  IN   THE   HOME 

There  is  perhaps  no  greater  bugbear  to  the  young  nurse  than 
the  prospect  of  having  to  prepare  for  an  operation  in  the  home. 
No  matter  how  excellent  her  course  of  training  may  have  been 
in  general,  she  very  rarely  has  learned  the  solutions  of  the 
many  practical  problems  which  will  arise  when  she  is  out  of 
reach  of  the  elaborate  equipment  and  the  ready-to-use  supplies 
which  made  life  comparatively  simple  for  her  in  the  hospital 
operating  room.  However,  the  nurse  who  has  learned  her  hos- 
pital lessons  best  will,  of  course,  succeed  best  in  the  home  be- 
cause operations  in  the  home,  while  they  do  not  call  for  new 
principles,  they  do  call  with  a  vengeance  for  special  combina- 
tions and  adaptations  of  the  old  ones.  This  is  really  a  hard- 
task  until  one  has  had  a  little  experience,  and  even  with  ex- 
perience each  home  will  make  some  new  demand  upon  one's  in- 
genuity and  technical  elasticity.  System  and  good  technic  are 
easy  in  the  hospital  operating  room  where  practice  has  stand- 
ardized everything  in  such  a  way  as  to  make  them  almost  auto- 
matic, but  in  the  home  natural  conditions  are  often  quite  ad- 
verse. One  can  always  succeed,  however,  by  virtue  of  the  very 
fact  which  often  hinders  system  in  the  hospital,  namely,  that 
there  are  so  many  roadways  to  Rome. 

"We  shall  now  assume  that  you  have  had  a  good  course  of 
training  in  the  hospital  operating  room,  that  you  have  studied 
Chapters  XIV  to  XVII  thoroughly,  and  that  you  have  in 
mind  clearly  the  things  you  will  need  and  your  general  course 
of  action,  and  with  this  for  your  armament  we  shall  take  you 
into  the  home  and  endeavor  to  guide  you  there  in  the  prepara- 
tion for  an  operation. 

If  you  have  been  nursing  the  patient  a  day  or  so  before  the 
operation  you  may  have  had  some  warning  and  will  therefore 
•  399 


400  TEXTBOOK  OF  SURGICAL  NURSING 

have  the  advantaiio  of  doing  some  ])reliiuiiiary  ])rc'paration 
leisurely.  If  you  are  ealk'd  on  sliorl  notice,  however,  you  must 
know  hoAv  to  make  the  most  of  your  time,  beeause  shortness  of 
time  is  not  ahvays  a  good  excuse  for  poor  vork.  In  general, 
then,  -vve  shall  say  that  when  you  are  called  to  jirepare  for  an 
operation  in  the  home  you  should  proceed  in  tliis  order: 

First  Step. — See  to  the  supply  of  sterile  gauze  dressings, 
towels,  sheets,  caps,  gowns,  masks,  and  gloves.  Often  the  sur- 
geon vill  have  these  in  readiness  in  his  office  and  you  vill  not 
need  to  supply  them.  In  other  cases  you  may  be  so  situated 
that  you  can  buy  CA^erything  you  will  need  from  some  supply 
house.  But  often  you  will  need  to  collect  the  best  supply  you 
can  find  about  the  house  or  elsewhere  and  sterilize  it  by  any 
means  you  can  devise. 

There  is  scarcely  any  substitute  for  gauze  in  an  operation, 
but  either  it  or  its  first  cousin,  cheesecloth,  will  be  available 
in  the  most  remote  place.  How  you  make  up  your  dressings 
will  depend  chiefly  upon  the  time  you  have,  but  be  as  simple  as 
possible.  If  the  operation  is  to  be  an  abdominal  one  you  should 
provide,  if  you.  can,  something  to  answer  the  purpose  of  the 
abdomiinal  tail  pads  described  on  page  224.  The  other  gauze 
supplies  besides  the  wipes  and  wound  dressings  will  depend 
entirely  upon  the  case. 

Gowns  will  not  be  found  in  the  home,  and  if  the  surgeon  does 
not  supply  them  you  will  need  to  substitute  something  else. 
About  the  onlj'  thing  you  can  use  is  a  large  muslin  sheet,  and 
this  can  be  made  to  work  very  well  indeed  by  draping  it  about 
the  body  in  some  such  fashion  as  that  illustrated  in  Fig.  149. 

Improvisation  of  the  cap  will  be  very  simple  for  any  nurse 
with  a  piece  of  muslin  or  gauze   (Fig.  149). 

Likewise,  the  face  mask  can  be  very  quickly  made  from  gauze 
or  muslin  (see  mask  C,  Fig.  45,  page  222). 

Sheets  and  towels  must  be  what  you  can  get,  but  always  use 
the  muslin  ones  rather  than  the  linen  if  you  have  a  choice,  as 
they  are  more  satisfactory  in  every  respect. 

It  will  rarely  ever  be  advisable  to  undertake  to  pi^jvide  a 
supply  of  dry  sterile  gloves  because  there  will  be  no  suitable 


OPERATIONS  IN  THE  HOME 


401 


home  method  of  sterilizing  them  thus,  and  their  preparation 
will  be  suggested  later  on. 

Perhaps  the  best  type  of  improvised  sterilizer  is  made  from 
a  wash  boiler  which  has  a  well-fitting  lid.  Fill  the  boiler  about 
one-fourth  (or  less)  full  of  water.     Suspend  the  parcels  to  be 


Fig.  149. — Improvised  Cap  and  Gowisr.  For  the  cap  a  piece  of  gauze 
about  1  yard  long  and  a  half  yard  wide  has  been  used.  Muslin  or  any 
similar  material  will  do  as  well.  The  gown  consists  simply  of  an  ordinary 
bed  sheet,  one  edge  of  it  being  laid  across  the  chest,  the  two  upper  corners 
crossed  in  the  back,  brought  up  over  the  shoulders,  and  pinned  to  the 
edge  in  front. 


sterilized  over  the  water,  and  just  clear  of  its  surface,  by  one 
of  the  following  methods:  (a)  Fasten  a  piece  of  muslin  across, 
hammock  fashion,  by  tying  the  ends  to  the  handles  of  the  boiler ; 
(&)  Make  a  platform  by  laying  narrow  strips  of  wood  upon 
pillars  of  bricks,  stones,  or  some  similar  heavy  household  article 
laid  in  the  bottom  of  the  boiler;  (c)  Lay  in  the  bottom  of  the 
boiler  anything  you  can  find  which  will  hold  the  supplies  to  be 
sterilized  above  the  surface  of  the  water  in  such  a  way  as  to 


402  TEXTBOOK  OF  SURGICAL  NURSING 

allow  free  circulation  of  the  steam  through  them,  particularly 
from  the  bottom  upward — a  kitchen  colander,  sieve,  or  a  wire 
dish-draining  tray  may  be  Avell  adapted  to  this  purpose.  Cover 
the  hoilrr  tightly.  After  the  water  has  reached  the  boiling 
])oiiit  tlie  lieat  siipi)ly  should  be  so  regulated  as  to  keep  it  barely 
boiling  because  the  steam  is  all  you  need  for  your  purpose  and 
you  gain  nothing  by  the  vigorous  boiling  except  unnecessary 
splashing  of  the  water  over  the  supplies.  If  the  cover  fits  well 
tlie  weight  of  it  Avill  compress  the  steam  slightly  and  thereby 
raise  its  temperature  someAvhat.  Do  not  make  the  mistake, 
however,  of  trj-ing  to  secure  the  lid  of  an  ordinary  wash  boiler 
sufficiently  to  make  it  steam  tight  as  this  may  result  very  dis- 
astrously. 

Continue  the  steaming  for  at  least  one  hour. 

The  parcels  must  then  he  dried,  of  course,  and  this  may  be 
done  in  the  kitchen  oven,  on  the  radiator,  in  the  sunshine,  or  if 
there  is  a  little  time  to  spare,  an  electric  fan  will  answer.  Care 
must  be  taken  when  using  the  kitchen  oven  not  to  have  it  so 
hot  that  it  will  scorch  the  supplies. 

The  haking  oven  also  furnishes  another  means  of  steriliza- 
tion. If  one  has  a  thermometer,  the  oven  can  be  made  to  serve 
quite  satisfactorily,  as  the  gauze  and  muslin  materials  are 
safe  from  scorching  below  300°F.  and  a  much  lower  tempera- 
ture than  that  wall  not  sterilize  unless  maintained  for  an  im- 
practicably long  time.  However,  in  the  absence  of  a  thermome- 
ter one  can  regulate  the  temperature  fairly  accurately  around 
the  scorching  point  by  testing  it  with  a  loose  piece  of  gauze 
or  muslin  or  a  piece  of  newspaper  and  regulating  the  supply  of 
heat  so  as  to  keep  the  temperature  just  below  this  point.  This 
is  a  rather  unrefined  method  but  it  is  better  than  none.  As 
the  parts  of  the  supplies  which  come  in  contact  with  the  metal 
of  the  oven  will  burn  sooner  than  the  free  parts,  it  is  advisable 
to  put  several  layers  of  newspaper  under  the  parcels,  as  this 
will  serve  as  an  insulator  and  will  also  show  when  the  oven  is 
too  hot  before  the  damage  spreads  to  the  supplies.  When  there 
is  a  shelf  in  the  oven  it  is  better  to  use  this  than  the  floor  of  it 
because  the  shelf  will  allow  better  distribution  of  the  heat. 


OPERATIONS  TN  TTTK  TiOME  403 

An  hour  should  be  aUowed  for  tliis  inciliod  ol"  sterilization 
also. 

Parcels  to  be  sterilized  by  such  improvised  methods  must 
not  be  made  too  large  nor  too  compact  because  the  lack  of 
pressure  and  exact  regulation  of  temperature  make  thorough 
penetration  rather  uncertain. 

In  a  very  rare  case  you  may  be  so  isolated  from  supplies  and 
so  short  of  time  that  you  cannot  apply  any  of  the  above  meth- 
ods of  sterilization.  In  such  an  emergency  it  would,  of  course, 
be  possible  to  get  along  by  boiling  towels  and  sheets,  and  even 
dressings,  and  using  them  wet,  but  such  an  exigency  is  so  im- 
probable as  scarcely  to  be  worthy  of  mention. 

Second  Step. — Select  the  most  suitaMe  room.  First,  deter- 
mine the  transportability  of  the  patient,  and  if  there  is  no  limi- 
tation on  that  ground  you  may  proceed  thus :  If  the  operation 
is  to  be  done  in  the  daytime  the  best  lighted  room  possible  is 
the  one  to  choose.  If  it  is  done  at  night,  or  if  there  is  not  good 
daylight  available,  consideration  must  be  given  to  the  artificial 
light  equipment  before  the  room  is  decided  upon. 

If  it  is  large  enough  and  has  the  necessary  light,  the  bathroom 
is  perhaps  the  best  one  because  it  can  be  most  easily  cleansed 
both  before  and  after  the  operation.  The  kitchen  is  perhaps 
the  last  choice  because  it  will  disturb  the  household  routine 
more  than  that  of  any  other,  and  the  sanitary  objections  from 
the  standpoint  of  both  the  kitchen  and  the  operation  are  very 
strong.  Of  the  remaining  rooms  the  choice  will  depend,  first 
of  all,  upon  the  light,  and  secondly  upon  the  amount  of  work 
and  confusion  necessary  to  adapt  them  for  the  purpose. 

Cases  in  which  you  are  obliged  to  use  an  otherwise  unde- 
sirable room  because  the  patient  cannot  be  moved  will  be  rare, 
and  you  will  have  to  make  the  best  of  the  situation;  but,  after 
all,  lack  of  light  would  be  about  the  only  serious  obstacle  which 
would  ever  arise  in  such  a  case. 

When  the  patient's  bedroom  itself  must  be  used  the  prepara- 
tion must  be  made  as  brief  and  simple  as  possible  because  it  will 
be  an  exceptional  patient  who  will  not  be  considerably  unnerved 
by  having  his  misfortune  thus  emphasized  for  him.  Screens 
will,  of  course,  help  in  most  cases  to  shield  the  patient  some- 


404  TEXTl'.OOK  OF  SFRCJITAL  NURSING 

■what,  l)iit  all  rcan-aiiucnit'iit  of  the  room  wliirli  is  not  abso- 
lutely necessary  should  be  avoided^  and  everyt]iin<;'  possible  of 
a  surgical  appearance  should  be  kept  outside  till  the  anesthesia 
has  been  started. 

Third  Step. — Renovate  the  room  ficlected.  This  step  can  be 
overdone  as  av(>11  as  underdone.  The  room  must,  of  course,  be 
thoroughly  clean,  but  if  little  time  is  to  intervene  between  the 
renovation  and  the  operation  the  removal  of  carpets,  pictures, 
etc.,  Avill  do  more  harm  than  good  by  raising  dust  which  will 
not  have  time  to  settle  sufficiently.  When  there  is  a  day's  warn- 
ing, for  instance,  Ave  should  remove  the  carpet  in  the  interest 
of  both  itself  and  the  operation,  but  it  is  d()ul)tful  that  it  is  ever 
necessary  to  go  to  the  extreme  of  removing  w^all  hangings  be- 
cause these  articles  can  usually  be  made  as  sanitary  as  the  walls 
themselves  by  careful  moist  dusting.  Also,  the  removal  of  fur- 
niture can  be  carried  to  an  extreme,  because  such  articles  as 
tables,  dressers,  etc.,  can  be  reasonably  cleaned  and  used  as 
convenient  pieces  of  operating  room  furniture.  One  must  use 
a  great  deal  of  common  sense  in  adapting  a  room  for  operations, 
and  in  doing  so  the  time  provided  will  take  first  place  in  mak- 
ing decisions,  confusion  of  the  household  second  place,  and  tech- 
nical convenience  last  place.  By  technical  convenience  we  do 
not  mean  technical  safety,  because  safety  can  be  secured  under 
almost  any  conditions  by  skilled  management  after  the  stage 
is  set. 

When  carpets  arc  left  in  place  they  must  he  carefully  covered 
both  for  their  own  protection  and  for  the  confinement  in  tliciu 
of  any  dust  which  might  otherwise  be  raised.  This  is  easily 
done  by  spreading  several  layers  of  newspaper  upon  them,  and 
if  the  lower  layer  is  moistened  with  Avater  we  may  feel  that  the 
room  is  very  well  insulated  from  the  dust  of  the  carpet.  Sheets 
may  be  tacked  down  over  the  newspapers  if  desired,  but  the 
newspapers  themselves  probably  make  a  better  floor  surface  for 
the  purpose  than  the  sheets.  A  large  rubber  sheet  immediately 
under  the  operating  table  is,  of  course,  ideal,  but  unless  it  is 
known  that  there  will  be  considerable  drainage  from  the  wound 
an  extra  amount  of  newspaper  will  serve  as  well.  The  practice 
of  covering  pictures,  furniture,  etc.,  Avith  sheets  is  a  doubtful 


OPERATIONS  IN  THE  HOME  405 

precaution  because  such  articles  can  nearly  always  be  made  as 
free  from  objectionable  features  as  the  sheets  themselves  by  judi- 
cious dusting. 

Windows  which  offer  a  view  to  the  neighborhood  may  be 
very  easily  "frosted"  by  rubbing  a  little  wet  "bon  ami"  or  a 
thick  lather  of  soap  over  them.  Sapolio  and  other  scouring 
powders  will  answer  but  nothing  is  so  easily  applied  and  re- 
moved as  the  "bon  ami." 

Fourth  Step. — Boil  some  water  and  set  it  aside  to  cool  for 
the  cold  sterile  water  you  may  need.  This  can  be  done  in  any 
large  vessel  you  can  find,  and  the  quantity  will  have  to  be 
judged  from  the  nature  of  the  operation  and  the  amount  your 
method  of  hand  sterilization  will  call  for. 

If  you  have  not  been  able  to  secure  sterile  salt  in  any  other 
form,  it  will  be  wise  at  this  time  to  provide  a  pint  or  more  of 
10%  salt  solution.  This  can  be  made  in  a  small  basin  or  kitchen 
pitcher  from  tap  water  and  table  salt,  and  boiled. 

Fifth  Step. — Provide  the  necessary  tables,  etc.  Some  surgeons 
will  bring  with  them  a  portable  folding  operating  table,  but  in 
the  absence  of  this  convenience  you  will  need  to  look  about  the 
home  for  a  good  substitute.  In  doing  this  it  must  be  kept  in 
mind  that  this  table  must  not  be  too  wide.  A  long,  narrow 
kitchen  or  library  table  will  often  be  suitable ;  two  shorter  tables 
may  be  placed  end-to-end;  a  strong  ironing  table  may  answer 
very  w^ell,  with  the  addition  of  a  small  stand  at  the  foot  if  it  is 
not  long  enough ;  a  narrow  door  may  be  taken  down  and  sup- 
ported upon  small  tables,  boxes,  etc.,  or  extension  boards  from 
a  dining  room  table,  or  any  other  boards,  may  be  utilized  simi- 
larly. The  height  of  any  of  these  tables  can  be  increased  if 
necessary  with  magazines,  books,  etc.  A  pad  of  blankets  or 
something  similar  must,  of  course,  be  provided  for  the  table. 

A  small  stand  that  may  be  drawn  up  to  the  operating  table 
will  be  suitable  for  the  instruments,  and  any  other  table,  dresser 
top,  etc.,  which  can  be  draped  sterilly  will  answer  for  the  re- 
serve sterile  supplies. 

If  a  folding  ironing  board  is  available  it  can  be  made  to  serve 
admirably  as  an  instrument  table  which  may  be  drawn  across 
the  operating  table. 


406  TEXTHOOK  OF  SURGICAL  NURSING 

For  fhe  anesthetist's  seat  a  small,  low  stand  may  answer,  books 
or  a  box  may  be  placed  upon  a  chair,  or  any  one  of  a  dozen 
substitutes  may  be  devised. 

Make  sure  that  there  will  he  the  proper  kind  of  light.  There 
will  usually  be  an  extension  light  of  some  kind  in  the  home 
which  may  be  appropriated  if  the  ordinary  light  of  the  room 
is  not  sufficient  or  is  inconveniently  located. 

Sixth  Step. —  Collcet  those  other  things  ivhich  will  need  to 
he  sterilized,  sueh  as  solution  basins,  pitcher,  irrigator,  hand 
brushes,  etc.  Recall  the  articles  we  have  listed  in  Chapter  XIV 
on  pages  212-213,  decide  upon  which  you  will  need,  and  then  se- 
lect the  best  substitute  available.  Hand  basins  and  the  other 
smaller  basins  can  usually  be  found  among  the  kitchen  equip- 
ment;  a  i)itrher  will  alwaj^s  be  at  hand;  a  rubber  douche  bag, 
or  a  kitchen  funnel  and  rubber  tube  will  take  the  place  of  the 
irrigating  can  for  irrigations,  infusions,  etc. ;  and  hand  brushes 
may  be  found  in  every  household. 

The  simplest  way  to  sterilize  these  things  is  to  boil  them  in  the 
Avash  boiler  or  some  large  kettle  on  the  kitchen  stove.  If  you 
cannot  find  anything  large  enough  in  which  to  do  this  you  may 
have  to  boil  the  larger  basins  directly  on  the  stove  with  the 
smaller  things  inside  of  them.  Basins  sterilized  in  this  way  will 
be  sterile  on  the  outside  as  Avell  as  the  inside,  but  after  standing 
over  a  gas  flame  or  a  stove  of  any  kind  it  must  be  remembered 
that  they  will  not  be  clean  enough  on  the  outside  to  associate  with 
the  other  supplies,  and  must  be  kept  away  from  them.  Some- 
times you  may  need  to  resort  to  the  method  of  sterilizing  the 
interiors  of  some  of  these  things  by  means  of  the  alcohol  flame 
as  described  in  Chapter  XV  on  page  242,  or  one  of  the  chemical 
solutions  may  have  to  serve.  With  careful  management  the 
unsterile  outsides  of  these  articles  will  not  do  any  harm. 

In  sterilizing  these  household  articles  great  consideration  must 
be  accorded  them,  and  nothing  should  be  used  in  any  way  that 
may  be  injurious  to  it  unless  the  family  is  w^illing  to  have  it  sacri- 
ficed. As  a  rule  the  family  will  place  anything  in  the  house  at 
your  service  at  this  time,  but  you  have  so  much  latitude  in  the 
way  of  substitutes  that  you  need  not  make  any  inroads  upon 
family  valuables. 


OPERATIONS  IN  THE  HOME  407 

At  this  time  boil  another  teakettleful  of  water  and  keep  it  hot 
for  the  hot  sterile  water  supply. 

Seventh  Step. — Collect  such  unsterile  articles  as  you  are 
likely  to  need.  Blankets  and  hot  water  bottles  are  always  easily 
secured ;  one  or  two  kitchen  pails  of  any  sort  will  answer  for  floor 
basins;  a  pillow  for  the  patient's  head  and  several  others  for 
adjustment  of  the  patient's  position  should  be  ready;  one  or 
two  extra  unsterile  sheets,  and  a  few  towels  will  be  needed; 
adhesive  plaster,  bandages,  and  safety  pins  are,  of  course,  ele- 
mentary provisions  for  all  operations. 

You  should,  of  course,  think  of  the  possibility  of  a  hypodermic 
of  some  stimulant  or  sedative  and  make  a  rule  of  having  your 
own  syringe  in  readiness,  though  the  surgeon  or  anesthetist  will 
doubtless  see  to  this  also. 

Provision  for  the  preparation  of  the  operative  field  should  also 
be  made  and  you  should  have  at  hand  whatever  of  the  probable 
things  you  can  secure.  Soap  and  alcohol  will  nearly  always  he 
available,  and  in  the  modern  household  you  will  be  very  likely 
to  find  iodine.  This  is  another  responsibility  of  which  the  sur- 
geon will  probably  relieve  you. 

Eighth  Step. — If  the  ruhher  gloves  have  not  ieen  otherwise 
prepared  you  will  now  hoil  them  for  about  5  minutes  with  the 
basins  and  other  things  which  have  been  boiling  and  then  store 
them  in  one  of  the  basins  in  some  antiseptic  solution.  It  is 
always  a  good  plan  when  boiling  a  number  of  gloves  to  put  them 
into  a  bag  for  the  process.  This  makes  handling  easier  and 
safer,  and  the  parcel  itself  can  simply  be  placed  in  the  solution 
basin  and  the  gloves  used  directly  from  it  without  any  previous 
handling. 

You  may  or  may  not  need  to  concern  yourself  about  the  instru- 
ments as  the  surgeon  may  bring  them  with  him  at  the  last 
moment  ready  for  use.  However,  unless  you  know  that  this  will 
be  the  case  you  should  have  boiling  soda  water  ready  for  them 
in  a  suitable  basin ;  or,  if  you  have  them  in  advance,  now  is  the 
time  to  see  that  they  are  boiled.  If  you  have  the  advantage  of 
an  electric  or  gas  boiler  or  a  portable  stove  of  any  kind  which 
may  be  heated  in  the  operating  room,  that  will  be  ideal,  as  it  is 


408  TEXTBOOK  OF  SURGICAL  NURSING 

always  a  comfort  to  have  the  instrument  boiler  reasonably  near 
the  operating:  table. 

Great  care  must  always  be  taken,  however,  with  an  open  fire 
of  any  -kind  in  the  operating  room  to  keep  it  a  safe  distance 
from  the  ether,  cldoroform,  or  ethyl  chloride,  as  these  anesthetics 
are  highly  inflammable.  Also,  intense  heat,  and  particularly  an 
open  flame,  decomposes  chloroform  vapor  and  forms  phosgene 
and  hydrochloric  acid  gases  which,  if  released  in  a  poorly  venti- 
lated or  small  room,  may  seriously  irritate  the  eyes  and  the 
respiratory  tract  of  the  occupants. 

Ninth  Step. — All  unsterile  supplies  being  in  place,  and  the 
sterile  ones  either  ready  or  almost  so,  about  one-half  hour  before 
the  appointed  time  for  the  operation  you  should  begin  the  sterile 
preparation  of  the  room. 

You  have,  of  course,  provided  a  place  and  the  supplies  for 
Ste7'ilizati\0)i  of  the  hands.  The  bathroom  basin  will  probably 
answer  this  purpose  whether  you  are  using  the  room  for  the 
operation  or  not.  Any  running  water  available  should  be 
utilized,  but  in  cases  where  there  is  none  you  will  need  to  provide 
hand  basins  and  plenty  of  both  unsterile  and  sterile  water  in 
pails  or  pitchers.  The  method  of  hand  sterilization  you  prepare 
for  will  depend  upon  Avhat  antiseptics  you  can  get,  but  in  most 
eases  you  can  follow  one  of  those  suggested  on  page  263. 

The  general  technic  for  '' setting  up"  the  room  can  be  the 
same  as  in  the  hospital.  Your  sterile  basins,  instruments,  etc., 
are  in  the  kitchen  or  wherever  you  may  have  boiled  them,  and 
if  they  cannot  be  transported  sterilly  by  an  unsterile  assistant 
you  may  have  to  bring  them  yourself  after  you  are  sterile.  If 
you  have  used  a  wash  boiler  the  probability  is  that  everything 
is  in  it  (with  the  exception  of  the  instruments  which  you  may 
have  boiled  separately)  and  unsterile  assistants  can  carry  this 
to  the  operating  room  when  you  are  ready  for  it. 

Dispose  all  the  sterile  supplies  as  accessibly  as  possible,  for 
assistants  will  usually  be  fewer  in  the  home  than  in  the  hospital 
and  you  will  have  to  perform  more  than  the  usual  duties  assigned 
to  one  person  there.  Also,  plan  well  ahead  for  the  unsterile 
work,  because  you  may  have  to  depend  upon  untrained  persons 
for  this. 


OPERATIONS  IN  THE  HOME  409 

The  first  one  or  two  operations  with  which  you  assist  in  the 
home,  especially  if  you  have  finished  your  hospital  training 
recently,  will  seem  somewhat  confused  technically;  but  if  you 
have  kept  everything  sterile  and  have  avoided  wastage  of  time 
for  your  patient  you  have  succeeded  well  and  have  doubtless 
broadened  your  education  to  the  extent  of  learning  that  there 
is  more  than  one  good  way  to  do  everything.  You  must  never 
expect  to  graduate  in  this  branch  of  work,  however,  for  no  two 
homes  wall  present  the  same  problems,  and  you  will  always  need 
to  be  prepared  to  rise  to  new  occasions. 

The  general  directions  for  draping  given  in  Chapter  XVI  on 
pages  266  to  290  may  be  followed  in  the  home  operation,  though 
greater  economy  in  sheets  and  towels  will  often  be  obligatory. 
Some  of  the  draping  accompaniments,  such  as  sandbags,  rubber 
sheets,  towel  clamps,  etc.,  will  doubtless  be  missing,  but  pillows, 
rolls  of  newspaper  or  magazines,  etc.,  well  bound  together  will 
take  the  place  of  sandbags;  newspaper  or  oilcloth  will  nearly 
always  answer  for  a  rubber  sheet;  and  safety  pins  will  make 
good  towel  clamps  if  artery  forceps  cannot  be  spared. 

As  cautioned  above,  have  all  sterile  supplies  within  as  easy 
reach  from  the  operating  table  as  possible  because  your  duties 
will  probably  be  manifold  during  the  operation,  and  you  may 
need  to  hold  a  retractor,  for  instance,  with  one  hand  while  you 
perform  the  instrument  passer's  duties  or  the  general  assistant 
nurse's  duties  with  the  other.  As  in  all  operating  room  manage- 
ment, time  spent  in  preliminary  planning  and  the  exercise  of 
good  common  sense  will  be  your  best  investments. 


Your  duties  after  the  operation  w'ill  depend  upon  circum- 
stances, but  in  any  case  you  will  make  sure  that  all  the  household 
articles  which  were  used  for  the  operation  are  put  into  proper 
condition  again  for  home  use.  This  applies  in  a  special  way  to 
the  household  linens.  All  blood-stained  pieces  should  be  rinsed 
clear  of  blood,  and  infected  ones  should  be  soaked  in  some  anti- 
septic solution  such  as  1-40  carbolic  or  1%  formalin;  for  it 
should  be  remembered  that  servants  and  members  of  the  family 
naturally  shrink  from  these  things,  and  that  outside  of  hospitals 
laundries  are  probably  not  prepared  to  treat  them  properly. 


410  TEXTBOOK  OF  SURGICAL  NURSING 

Likewise,  you  are  the  person  to  see  that  all  soiled  gauze  is  safely 
disposed  of,  and  that  the  other  articles  which  have  been  used 
are  thoroughly  cleansed  and  resterilized.  Also,  if  the  floor, 
walls,  or  other  parts  of  the  room  have  been  contaminated  in  any 
way  the  responsibility  is  yours  of  seeing  that  they  are  restored 
for  family  use.  In  other  words,  you  do  as  a  well-trained  nurse 
always  does,  namely,  leave  things  as  you  found  them.  AVhere 
servants  are  plentiful  you  will  doubtless  be  relieved  of  most  of 
the  reorganization  of  the  room,  but  sterilization  is  a  professional 
responsibility  and  you  should  not  delegate  any  part  of  it  to 
untrained  persons. 

What  you  do  in  the  home  with  instruments  or  other  things 
which  you  or  the  surgeon  may  have  brought  in  will  depend  upon 
whether  you  remain  to  nurse  the  patient  or  are  free.  If  you 
can  cleanse  and  resterilize  these  things  without  disturbance  to 
the  patient  it  will  be  better  practice  to  do  this  before  carrying 
them  about,  but  your  chief  concern  should  always  be  to  restore 
the  normal  conditions  of  the  home  as  soon  and  as  unobtrusively 
as  possible  under  existing  circumstances. 

IMPROVISED  OPERATIVE  POSITIONS 

The  arrangement  of  special  positions  will  be  rather  difficult 
in  cases  where  the  surgeon  does  not  provide  the  portable  oper- 
ating table,  and  even  then  some  of  the  more  elaborate  attach- 
ments will  doubtless  be  missing.  The  portable  tables  usually 
provide  for  the  lithotomy  and  Trendelenburg  positions,  but  for 
gall  bladder  and  kidney  positions  you  will  need  a  substitute  for 
the  elevating  attachment,  and  for  arm  cases  you  may  need  an 
arm  board  substitute.  The  following  suggestions  will  provide 
ways  out  of  these  difficulties: 

Trendelenburg  Position. — Sometimes  it  may  be  possible  to 
incline  the  entire  improvised  table  enough  to  answer  the  pur- 
pose, but  a  plan  which  can  always  be  used  in  the  home  is  to 
arrange  a  small  chair  on  the  table  as  illustrated  in  Fig.  150. 
To  overcome  the  tendency  of  the  patient  to  slide  on  this  the 
shoulders  may  be  lashed  to  the  table  by  means  of  a  strong  band- 
age or  a  small  sheet.  Pillows  and  blankets  must  be  freely  used 
with  this  contrivance  to  pad  or  supplement  it. 


OPERATIONS  IN  THE  HOME 


411 


Gall  Bladder  Position. — All  you  will  need  for  this  is  a  suit- 
able pillow  to  take  the  place  of  the  usual  table  rest  shown  in 
Fig.  65,  page  272. 

Kidney  Position. — A  large  pillow  will  be  needed  in  this  ease 
to  take  the  place  of  the  table  rest  (Fig.  67,  page  274).  Other 
pillows  will  make  good  substitutes  for  the  sandbags,  but  compact 
bundles  of  old  magazines  or  any  other  suitable  articles,  such  as 
sheets,  blankets,  etc.,  may  be  fitted  to  the  purpose. 


"Fig.  1.50. — Ordinary  Chair  Adapted  for  Improvisation  of  the  Tren- 
delenburg Position.  The  bandage  is  first  wound  very  tightly  from  leg  to 
leg  and  afterward,  to  keep  it  from  slipping  downward,  it  is  lashed  to  each 
leg  by  tying  a  short  piece  of  bandage  tightly  around  it  and  over  the  end 
of  the  leg.  It  will  be  necessary  to  use  plenty  of  pillows  or  folded  blankets 
over  the  bandage  and  the  back  of  the  chair,  both  for  the  protection  of 
the  patient  and  for  the  adjustment  of  his  position. 

Lithotomy  Position. — Some  means  of  supporting  the  legs 
will  be  your  first  concern  for  this  position.  There  are  several 
designs  of  "lithotomy  crutches"  (Fig.  151)  on  the  market  to 
which  you  may  have  access.  Otherwise,  a  large  sheet  may  be 
used  as  illustrated  in  Fig.  152.  This  sheet  has  been  folded 
diagonally  into  a  neat  strap  before  application  because  it  is 
more  compact  and  stronger  this  way.  Note  that  the  sheet  is 
passed  on  the  outside  of  the  thigh  rather  than  the  inside  before 
it  is  tied  or  pinned  below  the  knee,  because  otherwise  the  feet 


412 


TEXTBOOK  OF  SURGICAL  NURSING 


^vill  tend  to  turn  inward  ^\■lu'ro  they  will  be  in  the  way  of  the 
surgeon.  If  the  knees  tend  to  fall  so  far  outward  as  to  cause 
too  "much  strain  u|)i)n  the  hip  joints  the  banda<i'e  shown  in  the 


A  ^ 

Fig.  151. — Lithotomy  Crutches,  or  Leg  Holders,  for  Supporting  the 
Legs  in  the  Lithotomy  Position.  A,  of  the  illustration,  shows  the  essen- 
tial principles  of  the  Clover  crutch,  which  is  adjustable  in  all  parts.  The 
leg  straps  are  fastened  around  the  thighs ;  the  horizontal  portion  is  made 
of  metal  and  holds  the  legs  from  swaying  sidewise;  and  the  long  strap 
passes  underneath  the  back.  B  represents  the  Eobb  leg  holder.  This,  also, 
is  anchored  under  the  patient's  back. 


illustration  connecting  the  knees  should  be  used,  but  this  will 
not  always  be  necessary.  A  strong  bandage  or  any  other  strap- 
like contrivance  maj'-  be  used  instead  of  the  sheet.    In  some  cases 


Fig.  152. — Method  of  Improvising  a  Lithotomy  Crutch  from  an  Ordi- 
nary Sheet  Folded  into  a  Strap,  with  the  Addition  of  a  Few  Turns 
OP  A  Bandage  About  the  Thighs  if  Necessary. 

where  the  operation  is  to  be  short  and  there  are  assistants  avail- 
able two  persons  may  hold  the  legs  in  position. 

Some  substitute  for  the  Kelly  pad  will  he  necessary.  For 
this  you  wall  require  a  w'aterproof  sheet  of  some  sort  about  a 
yard  square.    In  the  absence  of  a  rubber  sheet  d>  piece  of  oil- 


OPERATIONS  IN  THE  HOME  413 

cloth  can  usually  Ik'  found.  Make  a  solid  roll  of  n('ws})a])f'r 
2  or  3  inches  in  diameter  and  3  or  4  feet  in  length  ;  bend  this 
into  a  semicircle,  lay  it  across  one  end  of  the  rubber  sheet  and 
then  roll  the  rubber  sheet  around  this  and  turn  them  inward 
together  until  they  are  securely  combined  and  are  the  desired 
size  and  shape.  You  should  then  have  a  pad  like  the  one  illus- 
trated in  Fig.  153. 

If  you  know  that  there  will  not  be  an  irrigation  during  the 
operation  or  that  there  will  not  be  drainage  of  any  kind  from 
the  wound  this  pad  will  not  be  needed. 


Fig.  153. — Improvised  Kelly  Pad.  A  rubber  sheet  or  a  piece  of  oilcloth, 
and  a  few  newspapers  rolled  together  and  bent  into  a  semicircle,  combined 
as  indicated,  are  all  that  one  needs  for  this  contrivance. 

A  pillow  or  old  magazines  will  make  the  substitute  for  the 
sandbag  which  you  may  or  may  not  need  under  the  hips. 

Arm  Position. — When  an  extra  rest  is  needed  for  an  arm 
case  a  small  side  table  may  be  used ;  or,  a  small  board  of  any 
kind  may  be  slipped  under  the  jDatient's  \)0&y  (underneath  the 
table  pad)  and  allowed  to  project  as  desired  (Fig.  79,  page 
283).  As  a  rule  the  weight  of  the  patient  wall  be  all  the  an- 
chorage necessary  for  this  board,  especially  if  it  is  long  enough 
to  extend  well  across  the  table. 


You  will  find  it  helpful  in  all  these  problems  of  improvisation 
to  take  as  your  guiding  star  the  result  you  wish  to  secure  rather 
than  the  passing  detail  of  making  or  finding  an  exact  copy  of 
some  convenience  you  have  learned  to  use  in  the  hospital, 
because  in  emergency  work  getting  the  operation  done  is  of 


414  TEXTBOOK  OF  SURGICAL  NURSING 

more  import am-o  tJiau  elegance  of  equipineiit.  This  is  not  meant 
as  an  indorsement  of  neglect  to  do  the  best  you  can  in  any 
respect,  but  merelj'  to  nrge  emi)hasis  upon  essentials.  In  this, 
as  in  all  human  activities,  experience  will  be  the  best  teacher. 


APPENDIX 


SOLUTIONS 


A  solution  is  a  liquid  which  has  dissolved  within  it  some  solid,  gas, 
or  other  liquid  substance. 

Liquids  differ  greatly  as  to  the  amount  of  any  given  substance  they 
can  hold  in  solution,  each  one  varies  with  its  temperature,  and  also 
there  are  wide  differences  among  the  various  substances  as  to  the 
amounts  of  them  Avhich  any  given  liquid  is  capable  of  dissolving.  The 
differences  pertaining  to  the  various  liquids  themselves  are  not  of  prac- 
tical interest  to  the  nurse  because  water  is  about  the  only  solvent  she 
uses,  so  the  folloAving  remarks  about  solutions  will  refer  to  those  made 
with  water,  and  the  substances  considered  will  be  only  the  more  com- 
mon ones  which  the  nurse  Avill  encounter  in  everyday  practice. 

Two  extreme  instances  of  the  limitations  Avhieh  substances  impose 
upon  the  solvent  power  of  water  are  those  of  silver  nitrate  and  boric 
acid.  We  can  dissolve  in  1  ounce  of  water  at  a  certain  temperature 
more  than  2  ounces  of  silver  nitrate  but  only  about  25  grains  of  boric 
acid,  and  if  we  put  any  greater  proportion  of  one  of  these  substances 
into  the  water  the  excess  will  merely  remain  undissolved  either  in  the 
bottom  of  the  container  or  in  suspension  in  the  water,  and  the  solution 
itself  will  be  what  is  called  a  saturated  one.  Likewise,  there  is  a  defi- 
nite saturation  point  for  every  other  substance. 

A  saturated  solution  of  any  given  substance,  then,  is  one  in  which 
the  liquid  is  holding  in  solution  all  of  the  substance  which  it  is  capable 
of  dissolving. 

The  poiver  of  water  to  dissolve  any  substance,  however,  varies  with 
the  temperature,  the  rule  being  that  the  higher  the  temperature  the 
more  it  can  hold  in  solution.  Therefore,  the  term  ''saturated  solution" 
is  only  a  relative  one.  In  the  following  table  of  a  few  substances 
frequently  used  by  the  nurse  are  given  the  amounts  of  water  in  which 
1  gram  of  the  substance  makes  a  saturated  solution.  The  figures  are 
those  given  in  the  United  States  Pharmacopoeia,  and  they  apply  only 
when  the  water  is  at  the  temperature  of  25°  Centigrade  (77°  Fahren- 
heit), which  is  the  temperature  adopted  in  the  Pharmacopoeia  as  tbe 
standard  normal  one.  The  milliliter  is  used  in  the  table  as  the  unit 
of  volume  instead  of  the  cubic  centimeter,  but  although  the  two  units 
are  not  quite  identical  they  are  given  the  same  apothecary  equivalent 
(16.23  minims)  and  it  does  not  matter,  for  present  purposes,  which 
term  is  applied. 

415 


416  APPENDIX 

Table  of  Amounts  of  Water  in  Which  1  G-ram  Makes  a  Saturated 

Solution 

Alum     7.2  mils 

Bichloride   of  niercuiT    lo.")     " 

Boric   acid    IS.O     " 

Carbolic  acid   lo.O     " 

Magnesimii  sulpliate   1.0  mil 

Potassium   perinanoanate   13.5  mils 

Silver  nitrate    0.4  mil 

Sodium  bicarbonate   10.0  mils 

Sodium  chloride   2.8     " 

With  a  table  of  figures  at  hand  for  reference  a  saturated  solution 
is  easy  to  make,  but  this  strength  of  any  substance  is  not  often  used 
and  the  nurse's  chief  concern  will  be  about  the  weaker  stjhilions  which 
she  will  have  to  make  either  from  the  undissolved  substance,  the  satu- 
rated solution,  or  from  a  solution  of  some  other  streugtli. 

The  strengths  of  solutions  are  indicated  either  by  the  per  cent  method, 
as  a  5%  solution,  or  by  the  arithmetical  ratio  metiiod,  as  a  1  in  20 
solution,  both  terms  showing  the  ratio  which  the  weight  of  the  dis- 
solved solid  substance  bears  to  the  corresponding  measure  of  the  whole 
amount  of  solution.  That  is,  they  Avill  stand  for  grains  in  minims, 
ounces  in  ounces,  grams  in  cubic  centimeters  or  mils,  etc.  For  large 
quantities,  of  course,  multiples  of  these  units  are  substituted  in  prac- 
tice, and  for  smaller  quantities  fractions  will  enter  into  the  compu- 
tation. 

T]ie  per  cent  method  of  reckoning  solutions  is  often  very  puzzling 
to  beginners,  but  it  is  in  reality  comparatively  easy  because  it  involves 
only  the  simple  rudiments  of  percentage.  The  term  per  cent  means 
merely,  by  the  hundred,  and  the  symbol,  '^'/c ,  is  only  an  abbreviated 
form  of  y-J-Q-  .  The  57f  solution,  tlien,  could  be  designated  as  a  y|  ^^ 
(five  one-hundredths)  solution,  or  a  5  in  100  solution,  which  means 
that  there  is  the  proportion  of  5  grains  in  every  100  minims.  This 
is  the  same  as  a  1  in  20  solution,  since,  if  there  are  5  parts  in  every 
100  parts  there  must  be  1  part  in  every  one-fifth  of  100,  or  1  in  every 
20  (usually  written  1-20).  Similarly,  the  process  of  division  may  be 
carried  into  fractions,  for  if  there  is  1  in  20,  there  must  be  ^2  iii  10> 
and  ^  in  5.  The  minim,  of  course,  is  not  divisible  in  practice,  but 
the  grain  may  be  fractioned  indefinitely,  as  will  be  shown  later  on. 
Also,  instead  of  dividing  both  these  numbers  they  may  be  multiplied, 
which  will  be  convenient  in  case  large  quantities  of  solutions  are  to 
be  made,  and  thus  the  1-20  solution  could  be  considered  a  10  in  200 
or  a  50  in  1000  solution,  and  so  on  indefinitely,  though  the  practical 


APPENDIX  417 

Ijlan  in  this  case  is  to  use  a  larger  unit,  such  as  the  dram  (fiO  grains 
or  minims),  the  ounce  (4cS0  i^rains  or  minims),  etc.,  instead  of  the 
single  grain  or  minim.  Similarly,  a  25%  solution  may  be  designated 
as  a  ^^^^,  25  in  100,  1  in  4,  or  a  1/4  in  1  solution,  and  so  on  for  any 
per  cent  of  strength. 

As  stated  above,  a  minim  can  not  be  divided  in  practice  and  there- 
fore it  will  occur  in  some  per  cents  of  strength  that  the  grains  and 
minims  are  not  in  such  ratio  that  1  grain  will  correspond  to  an  exact 
whole  number  of  minims.  In  an  8%  solution,  for  example,  there  are 
8  grains  in  100,  4  in  50,  and  2  in  25,  beyond  which  the  comparison 
can  not  be  carried  because  the  next  division  would  be  1  grain  in  121/2 
minims,  and  since  I2V2  minims  can  not  be  measured  it  can  not  be 
used  in  these  computations.  A  way  around  this  obstacle,  however,  is 
provided  later  on. 

Fractions  of  1%  are  a  little  different  problem,  but  they  present  no 
difficulties  if  they  are  regarded  as  merely  fractions  of  y-J-g--  For  in- 
stance, a  -|-  %  solution  is  a  ^  of  y^t?  ^  f^o''  ^i"  ^  1-500  solution. 

In  actual  practice  frequently,  when  large  quantities  of  a  solution 
are  to  be  made,  it  will  not  be  practicable  to  measure  the  solutions  in 
minims,  and  the  apothecary  dram  (60  minims)  and  the  ounce  (480 
minims)  will  be  rather  aAvkward  to  reconcile  with  the  per  cent  (1-100) 
system  of  reckoning.  A  universal  rule  which  covers  these  cases  is 
given  later  on,  but  occasionally  one  can  use  as  convenient  landmarks 
such  multiples  of  these  measures  as  5  drams,  for  instance,  which  eon- 
tain  300  roinims,  5  ounces,  which  contain  2400  minims,  and  so  on. 

We  can  now  make  a  solution  such,  for  instance, .as  a  2%  or  a  2-100 
one  of  boric  acid,  for  all  we  need  to  do  is  to  take  2  ounces  of  boric 
acid  and  add  enough  water  to  it  to  make  100  ounces  in  all.  The  stu- 
dent should  learn,  before  she  goes  further,  that  it  would  be  wrong  to 
make  this  solution  by  adding  2  ounces  of  boric  acid  to  100  ounces  of 
water  because  the  finished  solution  would  contain  more  than  100 
ounces  and  we  should  then  have  2  in  more  than  100.  Neither  would 
we  always  have  102  ounces  of  solution  in  such  a  case  because  the 
ounces  of  the  solid  substance  are  determined  by  apothecaries'  weight 
and  those  of  water  by  apothecaries'  measure,  and  they  are  not,  there- 
fore, to  be  reckoned  as  equal.  If  we  start  out  to  make  100  ounces  and 
make  all  calculations  for  that  amount  we  must  see  that  we  have  ex- 
actly 100  ounces  when  we  have  finished. 

The  real  problem  of  solution  making,  however,  arises  when  we  have 
to  make  a  limited  quantity  of  some  particular  strength,  and  the  be- 
ginner may  be  puzzled  to  know  hoAv  she  can  make  a  solution  of  1 
grain  in  1000  minims  of  water,  when  she  is  expected  to  make  only 
1  ounce  (480  minims).  But  a  second  thought  will  show  that  the 
1-1000  is  only  a  statement  of  a  ratio  and  not  a  prescription  of  a  whole 
grain  and  an  actual  1000  minims.     For  instance,  if  there  is  1  grain 


418  APPENDIX 

of  bichloride  in  1000  minims,  there  must  be  j'q  of  a  grain  in  100 
minims  andyJ-Q-of  a  grain  in  10  minims,  and  the  strength  of  the  1-1000 
sohition  could  be  written  -^^q -100,  -jJ^-lO,  and  so  on. 

In  the  following  jirobleius,  the  per  cent  and  the  ratio  designations 
of  solution  strengths  will  be  intermingled,  and  the  student  should  make 
it  a  point  to  be  able  to  translate  from  one  to  the  other  at  sight. 

Tableis  and  powders,  as  our  source  of  supply,  will  not  entail  any 
difficulties  except  those  which  arise  also  with  the  various  stock  solutions, 
so  we  shall  use  stock  solutions  chiefly  and  the  tablet  and  powder 
problems  will  take  care  of  themselves  at  the  same  time. 

Problem. — Make  5  ounces  of  2%  silver  nitrate  solution  from  a  25% 
stock  solution. 

In  quantities  no  larger  than  this  it  will  be  best  to  reduce  the  ounces 
to  minims,  first  of  all. 
Then,  5x480  =  2400 

The  total  number  of  minims  desired,  therefore,  is  2400;  and  as  2%, 
or  j|-^  of  this  amount  is  eventually  to  be  silver  nitrate, 
then,  2%  of  2400 

or,  y|-j5- X  2400  =  48,  the  number  of  grains  needed. 

The  next  step  is  to  get  this  48  grains  from  the  25%  stock  solution; 
and  this  solution  may  be  analyzed  thus : 

25  grains  =  100  minims 
5        "      =    20       " 
1  grain    =     4       " 

To  get  the  48  grains,  then,  we  take  from  the  stock  bottle  48  times 
the  quantity  which  contains  1  grain,  or, 

48  X  4  ^  192,  the  number  of  minims  to  take, 
=  3  drams,  12  minims. 

In  making  the  solution,  remember  that  this  3  drams  and  12  minims 
must  constitute  a  part  of  the  total  5  ounces  prescribed  instead  of  being 
an  addition  to  it.  This  will  be  clear  to  the  pupil  because  when  she 
started  out  she  desired  5  ounces,  not  5  ounces  plus  3  drams  and  32 
minims,  and  made  all  her  calculations  for  the  even  5  ounces.  The 
practical  way  of  securing  this  amount,  if  a  large  enough  measuie  is 
at  hand,  will  be  to  put  the  3  drams  and  12  minims  into  it  first  and 
then  add  water  up  to  the  5-ounce  mark.  If  a  smaller  measure  nuist 
be  used,  the  only  way  will  be  to  reckon  the  difference  between  5 
ounces  and  the  3  drams  and  12  minims  and  measure  out  only  that 
amount  of  water. 

Students  who  are  familiar  with  the  subject  of  algebraic  proportions 
will  find  it  very  applicable  in  a  ease  like  that  of  the  above  problem, 
for  we  can  reason  thus:  The  quantity  of  25%  solution  which  we  mr..st 
use  will  bear  the  same  relation  to  our  final  quantity  of  2%  solution  that 
2%  bears  to  25%' ;  and  with 


APPENDIX  419 

x'  =  quantity  of  stock  solution  we  nnist  use 
a  =  quantity  of  dilute  solution  we  are  making 
&  =  strength  of  dilute  solution  we  are  making 
c  =  strength   of  stock   solution 
we  can  state  our  problem  thus: 

x:  a^^  h  :  c 
In  other  words,  when  we  take  a  small  amount  of  25%  solution  and 
convert  it  into  a  larger  amount  of  2%  solution  we  merely  accept  the 
ratio  which  the  strengths  of  the  two  solutions  dictate  and  then,  by  the 
use  of  a  certain  quantity  of  water,  relate  such  portions  of  the  solutions 
as  have  the  inverse  of  their  strength  ratio.  Then,  we  can  solve  our 
problem  thus : 

Let  X  =^  the  number  of  minims  of  the  25%  solution  we  shall  have  to  use- 
Then,  :r:  2400  =  2%:  25% 
Solving  for  x,  25a;  =  2  x  2400 

=  4800 
a;  =  192 
Remember,  that  if  we  let  x  equal  the  number  of  minims  we  must  eon- 
vert  our  5  ounces  to  minims,  and  that  if  we  prefer  to  use  5  ounces  or 
40  drams  we  must  let  x  equal  the  number  of  ounces  or  drams. 

We  can  solve  any  form  of  solution  problem  with  this  formula  by 
merely  using  x  for  the  unknown  term.     Apply  it,  then,  to  the  same 
solution  under  the  following  various  conditions : 
Problem. — How  much  of  a  1-4  solution  of  silver  nitrate  will  be  needed 

to  make  5  ounces  of  a  2%  solution  f 
Let      X  =  the  number  of  minims  of  the  1-4  solution  needed, 
and  1-4  =  25%. 

Then,  a;:  2400  =  2%  :  25% 

2bx  =  4800 
«  =  192 
Or,  let       x  =  the  number  of  minims  of  the  1-4  solution  needed, 

and    2%  =  1-50. 
Then,  x :  2400  =  1-50 : 1-4 

=  4:50 
50:r  =  9600 
x  =  192 

Problem. — How  many  grains  of  silver  nitrate  will  he  needed  to  make  5 

ounces  of  a  2%  solution? 
Let  a;  =  the  number  of  grains  needed, 

and  2%  =  1-50.' 
Then,  a;:  2400  =  1:50 

50a;  =  2400 
a;  =  48 


420  APPENDIX 

Problem. —  117/rt/   /n   Ihe  slremjlh   of  a  silrcr  nil  rate  sohiliijn   in   which 

ihere  are  -iS  grains  of  silver  ))iiralc  lo  every  5  ounces? 
Let ,  X  =^  the  jier  cent  of  strength 

then,  a;-100  =  the  rnlio  of  strength 
Hence,  x :  100  =  48 :  2400 

2400a;  =  4800 
x  =  2 
and  a:-100  =  2-100 

=  1-50 

Problem. — Make  5  ounces  of  1-50  silver  nitraie  solution  from  a  25% 

solution. 
Let  .i'  =  the  nninl)ei'  of  minims  of  the  25%  solution  needed, 

and  1-50  =  2% 
Then,  :r:  2400  =  2%  :  25%> 

25a;  =  4800 
X  =  192 

Problem. — Hoiv  much  2%  solution  can  he  made  from  4S  grains  of  silver 

nitrate? 
Let  X  =^  the  number  of  minims  tlial  can  be  made, 

and  2%  =  1-50. 
Then,  48  :  a;  =  1 :  50 

or,  a; :  48  =  50  : 1 

X  =  2400 

The  above  method  works  perfectly  until  we  have  a  problem  that  re- 
quires us  to  use  a  stock  solution  which  will  not  yield  the  grains  or 
fractions  of  a  grain  we  need  in  whole  minims.  For  instance,  apply 
it  to  this 

Problem. — Make  1   ounce  of  I-  %   silver  nitrate  solution  from   a  5% 

solution. 
Let  a;  =  the  number  of  minims  of  the  5%^  solution  needed, 

and  1  ounce  =^  480  minims. 
Then,  x  :  480  =  i  %  :  5% 

5x  =4  A 
a;  =  13f 
Thus,   we    need    13#    minims.      But    Ave    can    not    measure  >-    of   a 

'  7  ' 

minim.  Li  many  cases  |  of  a  minim  would  be  so  unimportant  that 
it  could  be  dropped ;  but  if  we  were  dealing  with  morphine,  for  in- 
stance, it  would  not  be  unimportant  and  we  must,  therefore,  know  some 
way  out  of  such  a  difficulty. 

We  shall  now  formulate  a  rule  ivhich  icill  cover  the  most  involved 
fractions,  and  it  will  be  worth  while  for  the  ]iupil  to  work  this  out,  for 
when  she  has  done  so  she  will  be  equal  to  the  most  intricate  i^roblems 
and  will  understand  the  short  cuts  of  the  simple  ones  all  the  better. 


APPENDIX  421 

In  the  following  process  we  shall  deal  only  with  fractions  of  a 
grain  because  usually  any  whole  grains  that  may  be  needed  with  them 
could  be  taken  from  the  stock  solution  separately,  and  if  not,  the  whole 
number  and  the  fraction  could  be  reckoned  as  an  improper  fraction. 

Taking  the  above  problem  then,  we  can  analyze  it  thus : 
(1.)     What  fraction  of  a  grain  will  be  needed? 

1  ounce  =  480  minims 

J  %   or  -J_r  of  4Sfl  =  4  8  0  =:  2  4 

Therefore,  the  amount  of  silver  nitrate  needed  is  -|-|   of  a  grain. 

If  preferred,  this  question  may  be  answered  by  the  proportion  for- 
mula thus : 
Let  X  =  the  fraction  of  a  grain  needed, 

and  1  %  =  1-700. 
Then,   '  «:  480  =  1:700 

700j;  =  480 

-r.=:24 

(2.)      What  is  the  smallest  number  of  minims  that  may  be  taken  from 
the  stock  solution  which  will  yield  |^|-  of  a  grain? 
Analyze  the  5%  stock  solution  thus : 

5%=    5-100 
=   4-80 
=   3-  60 
=    2-  40 
=    1-  20 
=  3/4-15 
=  1/2-  10 
=  1/4-     5 
An  inspection  of  these  numerous  possibilities  shows  that  15  minims, 
containing  %  of  a  grain,  is  the  smallest  one  Avhieh  Avill  yield  the  neces- 
sary 11^  of  a  grain.     Therefore,  we  measure  out  15  minims  of  the  stock 
solution. 

(3.)     How  can  Y-k  of  a  grain  be  divided  so  that  exactly  |-|-  of  a  grain 
could  be  separated  from  it? 

If  the  3^  of  a  grain  were  made  up  of  thirty-fifths,  like  the  ||-  of  a 
grain  we  need,  it  Avould  be  easy  to  take  away  from  it  the  desired  24 
pai'ts.  But  the  quarters  of  any  whole  thing  can  never  contain  an  in- 
tegral number  of  its  thirty-fifths.  We  can,  however,  find  a  small  frac- 
tion of  a  grain  which  both  the  %  and  the  f-i  will  contain  exactly  in 
their  respective  proportions.  In  other  words,  we  can  find  a  common 
denominator  for  these  two  fractions. 
Then,  %  and  |-|.  =  iff  and  J^^ 

In  the  15  minims,  then,  there  are  105  parts  of  the  grain  of  the  same 
size  ( y|^   of  a  grain)  as  the  96  parts  which  we  wish  to  get  from  it. 


422  APPENDIX 

(4.)     How  can  15  minims  of  icater  he  divided  into  105  parts? 

The  addition  of  water  to  the  15  minims  of  silver  nitrate  solution  will 
not  change  the  amount  of  silver  nitrate  in  the  whole  quantity,  but  it 
will  change  the  amount  in  each  minim.  We  can,  therefore,  add  enongii 
minims  to  the  15  so  that  each  of  its  105  parts  of  a  grain  will  have  a 
certain  number  of  whole  minims  to  itself. 
Thus,        15  +    90  =  105  ^=  1  minim    for  each  y]^  of  a  grain, 

and        15  +  195  =  210  =  2  minims     "       "       "      ""      " 

and  so  on  indefinitely. 

With  a  different  stock  solution  it  might  have  happened  that  the  |2§" 
of  a  grain  were  in  more  than  105  minims  of  water  in  the  beginning. 
For  instance,  from  a  V2%  stock  solution,  150  minims  would  have  to 
be  taken  to  get  -]  5|  of  ^  grain. 
Then,       150  +    60  =  210  :=  2  minims  for  each  -j  ]  ^   of  a  grain, 

and      150  +  165  =  315  =  3  minims    ''        "        "     •  "  "       " 
and  so  on  indefinitely. 

Thus,  we  could  add  as  much  water  as  we  pleased  as  long  as  our  total 
number  of  minims  could  be  distributed  equally  among  the  105  parts  of 
a  grain  which  we  know  they  hold  in  solution.  In  other  words,  Ave 
must  add  to  our  portion  of  stock  solution  the  number  of  minims  of 
water  that  will  make  the  total  number  exactly  divisible  by  the  number 
of  parts  of  a  grain  which  are  in  it. 

(5.)     How,  then,  do  we  determine  the  actual  number  of  minims  which 
we  must  take  from  this  new  solution  in  order  to  get  exactly  the 
■f^  ''**  Tl%  ^f  ^  gfo-ii^  '?t'e  need? 
Since  jl^  =    1  minim 

then  -i\%  =  96  X  1 

=^  96  minims 

Therefore,  96  minims  will  be  the  amount  of  this  diluted  stock  solution 
to  use  to  get  -^-^  or  |-^  of  a  grain. 

Likewise,  if  y|-^  =  2  minims 

then  -^^  =  96  X  2 

=  192  minims, 
and  192  minims  would  be  the  portion  to  use. 

Then,  we  can  summarize  the  process  for  solving  fractional  solution 
problems  thus: 

(1.)     Determine  the  fraction  of  a  grain  needed. 

(2.)  Take  from  the  stock  solution  the  number  of  minims  which  con- 
tain the  fraction  of  a  grain  nearest  this  {at  least  as  large,  of 
course). 

(3.)     B educe  these  two  fractions  to  a  common  denominator. 

(4.)  Add  enough  water  {if  any  is  necessary)  to  the  portion  of  stock 
solution  so  that  the  total  number  of  minims  will  be  divisible  by 


APPENDIX  423 

the  number  of  parts  of  a  (jrain  which  it  contains  {the  numera- 
tor of  the  larger  fraction) ;  and  note  the  number  of  minims  pro- 
vided for  each  of  these  parts. 
(5.)  Multiply  this  number  of  minims  by  the  number  of  parts  of  the 
grain  needed  {the  numerator  of  the  smaller  fraction).  This 
will  be  the  number  of  minims  to  use. 

To  become  familiar  with  the  rule,  apply  it  step  by  step  to  several 
more  problems : 
Problem.' — Malte  1   ounce  of  \%   solution  of  boric  acid  from  a  4% 

stock  solution. 
(1.)         ^%  or  -^-^  of  480=  11^,  the  needed  fraction  of  a  grain. 
(2.)  4%  =4-100 

=  1-25 

Since  |^  is  very  little  less  than  1  grain,  a  whole  grain,  or  25  minims, 
will  have  to  be  taken  from  the  4%  stock  solution. 

(3.)  1  =  11 

Thus,  the  two  fractions  we  have  to  deal  with  already  have  a  common 
denominator. 

(4.)  Our  portion  of  stock  solution  is  25  minims,  a  number  which 
is  divisible  by  the  number  of  parts  of  a  grain  in  it,  so  no  water  need 
be  added  in  this  case;  and  we  have  1  minim  for  each  -^-^  of  a  grain. 

(5.)  .  24x1  =  24, 

and  24  is  therefore  the  number  of  minims  to  use  to  get  -||  of  a  grain 
of  boric  acid. 

The  experienced  student  will  be  able  to  solve  this  problem  by  mere 
inspection,  for  it  happens  that  steps  (3),  (4),  and  (5)  solved  them- 
selves in  the  nature  of  the  case  and  were  evident  at  a  glance. 

In  a  case  like. this  it  would  be  just  as  simple  to  put  the  whole  grain 
into  500  minims  of  water  and  discard  the  20  minims  containing  the 
unwanted  -gV  of  a  grain,  since  the  wastage  is  the  same  in  the  two 
cases  and  they  require  about  the  same  work  to  carry  out.  Sometimes, 
hovp^ever,  wastage  will  not  be  so  negligible,  and  it  will  not  always  be 
necessary  under  the  rule. 
Problem. — Make  4  ounces  of  1-7000  potassium  permanganate  solution 

from  a  1%  stock  solution. 
(1.)  1-7000  =  ^0% 

■^  %  of  4  ounces 

or,  -if^^  of  1920  =  ytjSg.,  the  fraction  of  a  grain  needed. 
(2.)  1%  =  1-100 

=  1/2-50 
=1-40 
=  1^-30 


424  APPF.NDTX 

The  ^  of  a  gTain  is  the  nearest  to  wiiat  we  need,  so  30  minims  is 

our  quantity. 

(^  )  =^.    anrl  -^  s^  r=  LO  o.  3,,^  -^K^^. 

(•^•J.  10    ''"'^'    170  35  0   **"•*   ^Bff* 

(4.)  .  30  +  75  =  105 

=^  1  minim  for  each  ^^  y  of  a  grain. 
(5.)  96  X     1  =  9G, 

and  96  is  therefore  the  number  of  minims  we  need  to  use  to  get  .^^q, 
or   .•♦.*V  of  a  grain. 
Problem, — Make  100  minims  of^%  cocaine  sohdiuu  from  a  J'/o  stock 

solution. 
(1.)  ^%  of  100  ^^g-,  the  fraction  of  a  grain  we  need. 

(2.)  1%  =  1-100 

=  1-50 
=    -40 
Therefore,  use  the  |  of  a  grain  in  40  minims. 

(3.)  I- and  -1=36^  and  t\ 

(4.)  40  +  2  =  42 

=  7  minims  to  each  j^g-  of  a  grain. 
(5.)  5x7^=35, 

and  therefore  35  minims  is  the  amount  tO'  use  to  get  j^^,  or  ^  of  a  grain. 
Problem. — Make  IY2.  ounces  of  1-1000  bichloride  solution  from  a  1-16 
stock  solution. 

(1.)  1%  ounces  =  720  minims 

1-1000  =  ^0% 
•Jy-%  of  720  minims  ^=  jVcfo' 

^  J-l,  the  fraction  of  a  grain  needed. 

2  5'  = 

(2.)  Stock  solution  =  1-16 

=  1/2-8 

=  1/4-4 

=  34-12 
The  12  minims  containing  %  of  a  grain  Avill  jaeld  the  amount  we 
Avish. 

(3.)  I    and   ^f  =  -^Vo    and  -j^q. 

(4.)  12  +  63  =  75  =  1  minim  to  each  -^ -J-^  of  a  grain. 

72  X    1  =  72,  the  number  of  minims  to  use. 

All  but  a  few  solutions  are  more  easily  and  quickly  made  with  warm 
water  than  with  cold,  and  as  they  are  nearly  always  warmed  for  use 
it  will  be  the  best  practice  to  warm  the  water  first.  In  making  a 
saturated  solution,  however,  the  element  of  temperature,  already 
pointed  out,  must  be  remembered. 

The  temperatures  of  water  understood  by  the  tei'ms  "cold,"  "warm," 
etc.,  as  ado])ted  in  the  IT.  S.  P.,  are  as  follows: 


APPENDIX  425 

Cold  water 15°-25°  Centigrade 

Lukewarm   water    35°-40°  " 

Warm  water   60°-70°  " 

Hot  water   85°-95°  " 

The  practice,  often  reconunended  to  nurses,  of  making  a  saturated 
solution  by  merely  putting  into  the  water  a  little  more  of  the  substance 
than  it  will  hold,  is  not  a  refined  one,  for  the  excess  is  always  in  the 
container  and  if  it  is  not  in  suspension  it  is  in  the  bottom  of  the  con- 
tainer and  becomes  mixed  in  solid  form  with  the  solution  every  time 
it  is  agitated.  The  nurse's  best  coarse  in  making  all  solutions  will  be 
to  measure  all  ingredients  accurately  and  she  will  then  know  exactly 
what  she  is  dealing  with. 

In  measuring  minims  of  any  solution  the  student  must  remember 
that  the  drop  is  not  a  permissible  substitute  for  the  minim.  The 
minim  is  an  invariable  and  standard  unit  of  measure,  while  the  size 
of  the  drop  varies  with  many  conditions,  chiefly  the  size  and  shape  of 
the  dropper,  the  temperature  of  the  liquid,  and  the  nature  of  the 
liquid.  Under  standard  conditions  a  drop  of  distilled  water  will  equal 
a  minim,  and  the  same  will  be  true  of  a  few  other  liquids,  but  among 
the  great  majority  of  liquids  there  are  striking  differences  in  the  size 
of  the  drop.  To  get  a  picture  of  the  inequality  of  drops  and  minims 
the  student  will  do  well  to  study  the  following  table  which  shows  the 
number  of  drops  in  a  dram  of  a  few  familiar  liquids  under  standard 
conditions.  The  fluid  dram,  of  course,  is  a  standard  measure  con- 
taining 60  minims. 

Table  of  Drops  in  a  Fluid  Dram 

Water 60 

Dilute   hydrochloric    acid    60 

Glycerine    67 

Castor   oil    77 

Balsam  of  Peru   101 

Tincture  of  digitalis   128 

Tincture   of   unx   vomica    140 

Aromatic  spirit  of  ammonia  142 

Alcohol   146 

Tincture  of  iodine   148 

Ether    176 

Chloroform    250 

The  nurse  will  usually  have  a  prescription  to  guide  her  as  to  the 
strength  of  any  solution  she  is  to  use,  but  a  reference  list  of  the  usual 
strengths  of  the  more  common  ones  is  given  below : 


426 


APPENDIX 


Usual  Strengths  cf  Solutions 

Alum    5% 

Argyrol    1-1000  to  25% 

Bichloride  of  moiruiy    1-1000  In  1-10,000 

Boric  acid   '2'.'<    to     T)'^ 

Carbolic  acid    1  -20  to  1-60 

Creolin     Vs'/r   to     2% 

Fornmliii      1/2%  to     1% 

Iclilliyol    3'/'   to  50% 

Lysul    1/2%  to     2%' 

Potassium    pennanoaiuite     1-1000  to  1-10,000 

Silver  nitrate   .  . .  „ 0.1%  to     5% 

Sodium    bicarbonate    1''/^    to  10% 

Sodium    chloride    0.6' ^    to  0.9% 

WEIGHTS  AND  MEASURES 
Apothecaries'  Weight 


•ound 

Ounces 

Drams                Scruples 

Grains 

lb. 

E 

3                          i. 

gr. 

1        = 

12 

=            96          =          288 

= 

5760 

1 

8          =            24 

= 

480 

1         =             3 

= 

60 

1 

= 

20 

Avoirdupois  Weight 

Pound 

Ounces                  Drams 

Grains 

lb. 

oz. 

dr. 

gr. 

1 

=           16 

=          256           = 

7000.0 

1 

=             16           = 

437.5 

1           = 

27.34375 

Metric  Weight 

s 

10 

milligrams    ^  1  centigram 

10 

centigrams    =1  decigram 

10 

decigrams     =  1  gram 

10 

grams            =  1  decagram 

10 

decagrams     ^  1  hectogram 

10 

hectograms    ^  1  kilogram  ■ 

10 

kilograms      =  1  myriagram 

10 

myriagranis  =  1  quintal 

10 

quintals          =  1  tonneau 

APPENDIX 


427 


a  .  . 

N» 

- 

- 

- 

O  o  CO 

CO 

tH 

CO 

o 

O  T-H  CO 

CO 
(M 

1—1 

CO 

CO 

o 

o 
o 

i-H 

CO 

^ 

■O 

lO 

O 

LO 

o 

t^ 

o 

iH 

o 

CO 

(./) 

^ 

-* 

II 

II 

f^ 

^ 

•73 

lO 

O 

lO 

1X5 

t^ 

I-H 

CO 
O  lO 

O 

-^ 

CO 

428  APPENDIX 


Apothecaries'    or    Wine    Measure 


Gallon 

Pints 

Fl 

iiidoiinces 

Fluidrams 

Minimi 

C. 

0. 

n 

f3 

m 

1 

8 

= 

128 

= 

1024 

= 

61,440 

1 

= 

16 

= 

128 

^ 

7,680 

1 

= 

8 
1 

— 

480 
60 

Metric  Dry  and  Liquid  Measure 


10  milliliters 

=  1  centiliter 

10  centiliters 

=  1  deciliter 

10  deciliters 

=  1  liter 

10  liters 

=  1  decaliter 

10  decaliters 

=  1  hectoliter 

10  hectoliters 

=  1  kiloliter 

10  kiloliters 

=  1  myrialitei 

APPENDIX 


429 


^  -     a 


CO   ci 


CO    O 
I-    o 

-*  O 


o  o 


o  o  o  o 

O    O  CO  o 

O    CO  cq  CCl 

'^il  CO  o 


> 


to    i:    ^    ^ 


o  o  <c>  o 
T-i   CO   1-'   CO 


CM    (M 


-^ 


CO    _ 

O    CO    O  CO  o 

1-5  CO  1^  CO  CO 

1— I  CO  CM 


O  -    i: 

O    ,-H    O 

i-i  ci  CO 


O 


430  APPENDIX 

EQUIVALENT  TEMPEKATl'HE  SCALES 

Ealirciiheit        Ceiitii;i-ade 
Degrees  Degrees 

Boiling  point  of  water   212 100 

200 });u 

li)() S7.S 

180 H2.2 

170 7U.7 

KiO 71.1 

150 C5.6 

140 60 

130 54.4 

120 48.9 

110 43.3 

Normal  bodj'  temperature 98.6 37 

90 32.2 

80 26.7 

70 21.1 

60 15.6 

50 10 

40 -. ...     4.4 

Freezing  point  of  water 32 0 

20. —6.7 

10 —12.2 

0 —17.8 

The  Fahrenheit  scale  is  used  chiefly  in  the  English-speaking  coun- 
tries. The  Centigrade  scale  is  used  in  Europe  and  Latin-America 
chiefly,  but  it  is  considerably  used  also  in  most  of  the  other  countries. 

Tlie  conversion  of  any  given  reading  of  one  scale  into  its  equivalent 
in  the  other  is  very  easy.  If  32  (the  number  of  degrees  below  the 
freezing  point  in  the  Fahrenheit  scale)  is  subtracted  from  212  (the 
boiling  point  on  the  Fahrenheit  scale)  the  remainder  will  be  180,  which 
is  the  actual  number  of  degrees  on  the  Fahrenheit  scale  between  freez- 
ing and  boiling.  On  the  Centigrade  scale  the  corresponding  number 
is  100.  Then,  any  given  number  of  degrees  on  the  Fahrenheit  scale 
(after  32  has  been  subtracted)  is  to  the  corresponding  one  on  the 
Centigrade  scale  as  180  is  to  100,  or,  reduced  to  lowest  terms,  as  9  is 
to  5.  In  other  words,  the  Centigrade  reading  will  be  five-ninths  (|) 
of  the  Fahrenheit  one. 

Example. — Convert  98.6°  Fahrenheit  into  Centigrade. 
98.6  —  32  =  66.6 

66.6  X  ;]    =  37,    the  corresponding  reading  on  the  Centi- 
grade thermometer. 


APPENDIX  431 

To  work  the  problem  backward,  and  convert  Cenligrade  degrees  into 
Fahrenheit  ones,  the  fraction  will  sini])ly  be  inverted;  that  is,  the 
Centigrade  degrees  will  be  multiplied  by  nine-fifths  (5).  It  must  be 
remembered,  however,  that  the  resulting  figure  will  represent  only  the 
number  of  degrees  above  the  freezing  point  on  the  Fahrenheit  scale, 
and  32  must  be  added  in  this  case  to  get  the  true  Fahrenheit  reading. 
Example.- — Convert  37°  Centigrade  into  Fahrenheit. 

37     x-|    =66.0 

66.6  +  32^=98.6,  the  true  corresponding  reading  on  the 
Fahrenheit  thermometer. 


ABBREVIATIONS  AND  SYMBOLS 

aa,  ana,  equal  parts  of  each. 

A.c,  ante  cihum,  before  meals. 

Ad,  to,  up  to. 

A.D.,  auris  dexter^  right  ear. 

Ad  2  vie,  ad  duas  vices,  for  two  doses. 

Add.,  adde,  add  to  it. 

Ad  lib.,  ad  libitum,  whenever  desired. 

Ag  argentum,  silver. 

Al  aluminum. 

Al.  dieb.,  alterius  diebus,  every  other  day. 

Alt.  hor.,  alterius  horis,  every  other  hour. 

Alt.  noc,  alterna  node,  every  other  night. 

Aq.,  aqua^  water. 

Aq.  astr.,  aqua  astricta,  ice. 

Aq.  bull.,  aqua  bulliens,  boiling  water. 

Aq.  com.,  aqua  communis,  common  water. 

Aq.  dest.,  aqua  destillata,  distilled  water. 

Aq.  ferv.,  aqua  fervens,  hot  water. 

Aq.  pur.,  aqua  pura,  pure  water. 

As,  arsenic. 

A.  S.,  auris  sinister,  left  ear. 
At.  wt.,  atomic  weight. 

An,  aurum,  gold. 
Av.,  avoirdupois. 
Bi,  bismuth. 
Bib.,  bibe,  drink. 

B.  i.  d.,  bis  in  die,  twice  a  day. 
Bis,  twice. 

Bis  hor.,  bis  horis,  every  two  hours. 

Br,  bromine. 

Bull.,  bulliat,  let  it  boil. 


432  APPENDIX 

c.,  cum,  with. 

C,  carbon,  oentiorade. 

C,  or  Cong'.,  congius,  a  gallon. 

Ca,  calcium.- 

Calef.,  calefactus,  warm,  let  it  be  made  warm. 

Cap.,  capiat,  let  him  take. 

C.c,  cubic  cc'iitinieter. 

Ce,  cerium. 

Cent.,  centigrade. 

Cg.,  centigram. 

Cib.,  cibus,  food. 

CI,  chlorine. 

Cm.,  centimeter. 

C.  m.,  eras  mane,  tomorrow  morning. 

C.  m.  s.,  eras  mane  sumendus,  to  be  taken  tomorrow  morning. 

C.  n.,  eras  node,  tomorrow  night. 

Cochl.,  cochleare,  spoonful. 

Cochleat.,  cochleatim,  by  spoonfuls. 

Coehl.  ampl.,  cochleare  amplum,  a  tablespoonful. 

Cochl.  infant.,  cochleare  infantis,  a  teasi)oonful. 

Coehl.  mag-.,  cochleare  magnum,  a  tablespoonful. 

Coehl.  med.,  cochleare  meclum,  a  dessertspoonful. 

Cochl.  para  v.,  cochleare  parvum,  a  teaspoonful. 

Col.,  cola,  strain. 

Colet.,  eoletur,  let  it  be  strained. 

Collut.,  collutorium,  a  mouth  wash. 

Collyr.,  collyrium,  a  mouth  wash. 

Comp.,  compositus,  compound. 

Cong.,  congius,  gallon. 

Cons.,  eonserva,  keep. 

Contim.,  eontimetur,  let  it  be  continued. 

Cont.  rem.,  eontimetur  remedia,  let  the  medicine  be  continued. 

Coq.,  coque,  boil. 

Coq.  in  s.  a.,  coque  in  sufficienle  aqua,  boil  in  sufficient  water. 

C.  P.,  chemically  pure. 

Crast.,  erastinus,  for  tomorrow. 

Cu,  cuprum-,  copper. 

C.  v.,  eras  vespere,  tomorrow  evening. 

Cwt.,  a  hundredweight. 

Cyath.,  cyathus,  a  glassful. 

Cyath.  vin.,  cyathus  vinarius,  a  wine  glass. 

Decoct,  hord.,  decoctum  hordei,  barley  water. 

Deeub.,  decubitus,  lying  down. 

De  d.  in  d.,  de  die  in  diem,  from  day  to  day. 

Deg.,  degree. 


APPENDIX  433 

Deglut.,  deylutiatur,  let  it  be  swallowed. 

Dep.,  depuratus,  purified. 

Destil.,  destilla,  distil. 

Det.,  detur,  let  it  be  given. 

Det.  in  dup.,  det.  in  2plo,  detur  in  duplo,  let  twice  as  much  be  given. 

Dieb.  alt.,  diebus  alterius,  on  alternate  days. 

Dieb.  tert.,  diebus  teriius^  every  third  day. 

Dil.,  dilue,  let  it  be  dissolved. 

Dil.,  dilutus,  dilute.  , 

Dim.,  dimidius,  one-half. 

D.  in  p.,  divide  in  partes  aequales,  divide  into  equal  parts. 

Div.,  divide. 

Donee,  alv.  sol.  fuerit.,  donee  alvus  soluta  fuerit,  until  the  bowels  are 

opened. 
Dr.,  dram. 

Dur.  dolor.,  durante  dolore,  while  the  pain  lasts. 
Ejusd.,  ejusdem,  of  the  same. 
Elix.,  elixir. 

Emp.,  emplastrum,  a  plaster. 
Emp.  vesic,  emplastrum  vesicatorum,  a  blister. 
Enem.,  enema. 

Exhib.,  exhibeatur,  let  it  be  given. 
Ext.,  extract,  external. 
F.,  fac,  make. 
Fahr.,  Fahrenheit. 
Fe,  ferrum,  iron. 

Feb.  dur.,  febre  duranti,  while  the  fever  lasts. 
Fid.,  fluid. 

F.  mist.,  f,at  mistura,  make  a  mixture. 
Fot.,  fotus,  a  fomentation. 
F.  pil.,  fiat  pilula,  make  a  pill. 
Fract.  dos.,  fracta  dosi,  in  divided  doses. 
Freq.,  frequenter,  frequently. 
Ft.,  flat,  let  it  be  made. 
F3,  fltiicl  dram. 
F3,  fluid  ounce. 
Garg.,  gargarisma,  a  gargle. 
Gm.,  gram. 
Gr.,  grain. 
Gtt.,  guttae,  drops. 
Guttat.,  guttatim,  by  drops. 
H,  hydrogen. 

Hd.,  hora  decubitus,  at  bedtime. 
Hg,  hydrargyrum,  mercury. 
Hor.  deeub.,  liora  decubitus,  at  bedtime. 


434  APPENDIX 

H.  s..  hora  .suiniii,  at  bedtime. 

r,  iodine. 

Id.,  ideui,  (lie  irianie. 

In  a(|.,  in  aqua,  in  water. 

In  d.,  in  die,  daily. 

Inf.,  infusum,  an   int'nsion. 

Inject.,  injectis,  an   injection. 

K,  kaliiim,  pota.ssium. 

Kji'.,  kilogram. 

L.,  liter. 

Lat.  dol.,  lateri  dolenti,  to  the  painfid  side. 

Lb.,  libra,  a  jionnd. 

Li,  lithium. 

Lin.,  linimenHiWy  liniment. 

Liq.,  liquor. 

Loe.  dol.,  loco  dolenti^  to  the  painful  spot. 

Lot.,  lolio,  a  lotion. 

M.,  misce,  mix. 

Mae.,  macera,  macerate. 

IMan.,  manii).,  marnpidus,  a  handful. 

Man.  pr.,  inane  primo,  early  in  tlie  morning. 

Mass.  pil.,  massa  pilularum,  pill-mass. 

Matut.,  matutinus,  in  the  mornino-. 

M.  et  N.,  mane  et  node,  morning  and  night. 

M.  ft.,  let  a  mixture  be  made. 

Mg,  mag-nesium. 

Mist.,  mistura,  a  mixture. 

Mn,  manganese. 

Mor.  diet.,  more  dido,  in  the  manner  directed. 

Mor.  sol.,  more  solito,  in  the  usual  way. 

N,  nitrogen. 

Na,  sodium. 

Ne  rep.,  ne  repetatur,  not  to  be  repeated. 

Noct.,  node,  at  night. 

Noct.  maneq.,  node  maneque,  at  night  and  in  the  morning. 

Non  repetat.,  non  repetatur,  do  not  repeat. 

0,  oxygen. 

0.,  odarius,  a  pint. 

0-,  both  eyes. 

0.  d.,  omne  die,  every  day. 

0.  D.,  ocidus  dexter,  right  eye. 
01.,  oleum,  oil. 

01.  oliv.,  oleum  olivae,  olive  oil. 
O.  m.,  omni  mane,  every  morning. 
Omn.  bih.,  omni  bihora,  every  two  hours. 


APPENDIX  435 

Omn.  hoi.,  omni  hora,  every  hour. 

Omii.  noct.,  omni  node,  every  night. 

O.-n.,  omni  node,  every  night. 

0.  S.,  oculus  sinister,  left  eye. 

0.  U.,  oculus  uterque,  either  eye. 

Ov.,  ovum,  an  egg. 

Oz.,  ounce. 

P,  phosphorus. 

P.  or  pug.,  pugillus,  a  pinch. 

Part,  aeq.,  partes  aequales,  equal  parts. 

Part,  vie,  partihus  vicibus,  in  divided  dose.s. 

Pb.,  plumbum,  lead. 

P.  c,  post  cibum,  after  meals.  , 

Pil.,  pilula,  a  pill. 

Pond.,  pondere,  by  weight. 

P.  rat.  aetat.,  pro  rata  aetatis,  in  proiDortion  to  the  age. 

P.  r.  n.,  pro  re  nata,  according  to  need. 

Pro,  for. 

Pt.,  pint. 

Pulv.,  pulvis,  powder. 

Q.  d.,  quarter  in  die,  four  times  a  day. 

Q.  h.,  quaque  hora,  every  hour. 

Q.  i.  d.,  quarter  in  die,  four  times  a  day. 

Q.  1.,  quantum  libet,  as  much  as  you  choose. 

Q.  p.,  quantum  placeat,  at  will. 

Q.  q.  h.,  quaque  quarta  hora,  every  fourth  hour. 

Q.  s.,  quantum  sufficit,  as  much  as  is  necessary. 

Qt.,  quart. 

Quotid.,  quotidie,  daily. 

Q.  v.,  quantum  vis,  as  much  as  you  wish. 

Ra,  radium. 

Rad.,  radix,  root. 

Rect.,  rectificatus,  rectified. 

Rep.,  repetatur,  let  it  be  repeated. 

S.,  sine,  without. 

S.  or  sig.,  signa,  write. 

Sat.,  saturated. 

Sb,  stibium,  antimony. 

Semih.,  semihora,  half  an  hour. 

Sig.,  signetur,  let  it  be  labeled. 

Sig.,  signa,  write. 

Simul,  together. 

Sing.,  singulorum,  of  each. 

Sol.,  solution. 

Solv.,  solve,  dissolve. 


436  APPENDIX 

S.  0.  s.,  si  opus  sit,  if  necessary. 

Sp.,  spiritus,  spirit. 

Sp.  gr.,  specific  gravity. 

Spir.,  spiritus,  spirit. 

Spt.,  spiriHis,  spirit. 

St.,  stet,  let  it  stand. 

Stat.,  stall m,  at  once. 

Ss.,  semissis,  a  half. 

Sii.,  sumet,  lot  liiin  lake. 

Sum.,  sumendus,  to  be  taken. 

S.  v.,  S2)iritiis  vini,  alcoholic  si)irit. 

S.  V.  r.,  spiritus  vini  rectificatus,  rectified  S]»irit  of  wine. 

S.  V.  t.,  spiritus  vini  tenuis,  dilute  alcohol,  proof  spirit. 

Syr.,  syrup. 

T.,  temperature. 

T.,  ter,  three  times.  , 

T.  i.  d.,  ter  in  die,  three  times  a  day. 

Tinct.,   tincture. 

Tr.,  tincture. 

Ult.  praes.,  ultimum  prcEscriptus ,  last  prescribed. 

Ung.,  unguentum,  ointment. 

U.  S.  P.,  United  States  Pharmacopoeia. 

Ut  diet.,  ut  dictum,  as  directed. 

Vitel.,  xitellus,  yolk. 

Vitel.  ovi,  vitellus  ovi,  yolk  of  egg. 

Viz.,  videlicet,  namely. 

Wt.,  weight. 

Zn,  zinc. 

5,  dram. 

B,  ounce. 

3,  scruple. 

B,  recipe,  take. 

iTi,  minim. 


INDEX 


Abbreviations  and  symbols,  431 
Abdomen,  bandage  for,  389 

distention  of,  23 

pads  for,  213,  223,  247 

paracentesis  of,  68 
Abrasion,   130 
Abscess,   10 

in  appendicitis,  59 

ischiorectal,  61 

of  brain,  83 

of  liver,  68 

peritonsillar,  43 

secondary,  59 
Acidosis,  21 
Acromegaly,  73 
Actual  cautery,  236,  242 
Adenoids,  instruments  for,  44,  305 

surgery  of,  44 
Adhesive    plaster,    and   tape    device, 
317 

removal  of,  317 
After    care    of    anesthesia    patients, 

180 
Agents,  sterilizing,  235 
Air,  hot,   sterilization  by,   236,   241, 
252,  254,  258,  257,  258,  402 

sterilizer  for,  241 
Albolene  silk  thread,  229,  260 
Albuminuria,  187,  190 
Alcohol,  74,  105,  117,  140,  242,  246, 
252,  258,  266,  406,  407 

flame  sterilization,  242,  406 
Algebraic  proportions,  418 
Alimentary  system,  38-71 
Alkalinity,  Dakin's  test  for,  354 
Aluminum-bronze  wire,  229,  230,  261, 

307 
Ambrine,   137 
Amputations,   102-104 

instruments  and  sutures  for,   103, 
309 

retractors  for,  212,  213 
Anaphylaxis,  37 
Anastomosis,  intestinal,  53,  67 
Anchorage  of  roller  bandage,  366 
Anesthesia,   173-192 

care  of  patient  in,  175,  180 

chloroform,  179,  189 

complications  after,  180,  182,  184, 
186,  187,  188,  189,  190,  191 

ether,  178,   183 


Anesthesia,   ethyl   chloride,    179,    190 

intratracheal,  41 

nitrous  oxide,  178,  182 

preparation  of  patient  for,   1 73 

pulse  in,   177,   178,   179,   180,   182, 
187,   190,   191 

respirations     in,     182,     183,     189, 
191 
Anesthetist,  isolation  of  from  opera- 
tive field,  287,  288 
Anesthetizing  room,   195,   204,   265 
Ankle  bandage,  370,  377 
Anthrax  spores,  259 
Anti-constipation  diet,  169 
Anti-obesity  diet,  171 
Antiseptic,  definition  of,  233 

solutions,   130,  245 

surgery,   history   of,   ix-xv 
Antrum  of  Highmore,  121 
Anus,   artificial,   56 
Apothecaries',  measure,  428 

weight,  426 
Appendicectomy,  57-60 

instrument  passing  for,  297 
Appendicitis,   56-60 
Applying  the  roller  bandage,  modes 

of,  365 
Aprons,  muslin,  212,  214,  247 

rubber,  212,  214,  251 
Arms,    arrangement    of    for    opera- 
tions,   177,    268,   273,    275,    278, 
280,  282,  288 

bandage   for,   368,   373,   375,   388, 
389 

basins  for,  207 

board  for,  283,  413 

draping  of,  282,  283 

operative  position  for,  283,  413 

Thomas  traction  splint  for,  100 
Arrangement    of    operating    theater, 

193 
Arteries,     instruments    and     sutures 

for,    305 
Artificial  anus,  56 
Aseptic,  definition  of,  233 

surgery,  history  of,  ix-xv 
Asphyxia,   184 
Autointoxication,  27" 
Autonomic  system,  80 
Avoirdupois  weight,  426 
Axilla,  bandage  for,  384 


437 


438 


INDEX 


Back,  operative  position  and  draping 

for,  276 
Bactereniia,  10 
Bacteria,  classification  of,   12 

count-   of    in    Carrel-Dakin    treat- 
ment, 345 

]>ortals  of  entry  for,  12 
Bactericide,  definition  of,  233 
Bap,  colostomy,  61 
Bakinjr,  89,  92 
Balkan  frame,  98 
Bandage,  abdominal,  389 

anchorage  of,  366 

ankle,  370,  377 

application  of  to  various  parts  of 
the  body,  373 

arm,  368,  373,  375,  388,  389 

axilla,  384 

Barton,  381 

Bier's,   391 

breast,   385,   389 

Canton  flannel,  359,  360 

capeline,   383 

chest,  388,  389 

chin,  381,  382,  389 

circular,  366 

crepe  paper,  360,  361 

definition  of,  355 

double  roller,  382 

durability  of,  363,  364 

ear,  380 

elastic  webbing,  360 

elbow,  375 

Esmareh,  102,  212,  252,  360,  390 

evenness  of  pressure  of,  363 

eye,  378 

face,  381 

fastening  of,  392 

figure-of-8,  370 

finger,  373 

flannel,  212,  360 

foot,  376,  377,  388 

for  fractures,  88 

for  pressure,  391,  392 

forms  of,  356 

gauze,  212,  359,  360 

hand,  373,  375,  388 

head,  366,  372,  382,  388,  389 

heel,   377 

hip,   387,  388 

jaw,  381,  382,  389 

knee,  378 

leg,  376,  377,  378,  389 

many-tailed,  358,   362,  363,   389 

materials  used  for,  359 

muslin,   212,   360 

neatness  of,  363,  364 

plaster  of  Paris,  91,  212,  361,  390, 
397 

pressure  of,   363 


Bandage,  recurrent,  372 

removal  of,  396 

reverse,  368 

roller,  356,  359,  362,  365,  373,  382 

rcdliiig  of,  356 

rubber,   102,   212,   252,   360,   390 

scissors  for,  319,  396,  397 

Scultetus,  358,  389 

shoulder,  384,  388 

sizes  of,  362 

spica,  93,  374,  384,  387 

spiral,   367 

starfli,    212,   360,   390 

tension  of,  363 

thumb,   374 

toe,   376 

triangular,   362,   388 

uses  of,  355 

A'elpcau,  384 
Bandages,  212,  214,  247,  326,  331 
Bandaging,  355-398 

definition  of,  355 

principles  of,  363  ' 

rules  for,  394 
Bands,  rubber,  213,  225,  247,  311 
Bartlett  method  of  catgut  steriliza- 
tion,  257 
Barton  bandage,  381 
Basins,  arm,  207 

floor,  214 

solution,   200,   212,   214,   246,   325, 
328,   406 

wash,  206 
Bath,  Sitz,  63 
Bathroom,  as  home  operating  room, 

403 
Beck's  paste,  56 

Bed,  for  anesthesia  patient.  29,  181, 
191 

Gatch,  29 
Bedroom,   as   home   operating   room, 

403 
Bellevue  bridge,  71 
Benches,   floor,   200 
Benign  growths,  13 
Bichloride  of  mercury,  246,  248,  250, 
263,    264,    266,    320,    321,    322, 
332 
Bier  's  bandage,  391 
Bigelow  evacuator,  148 
Bile  ducts,  65 
Bladder,  urinary,  145-149 

in  anesthesia,  175,  188,  190 

instruments  and  sutures  for,   148, 
309 

operative  position  and  dra[)ing  for, 
267 
Blankets,  29,  175,  180,  181,  191,  212, 

214 
Bleeding,  capillary,  17,  18 


INDEX 


439 


Blood,  clot  of,  4,  35 
clotting  time  of,  36 
defibrinated,   17 
grouping  of,  15 
"poisoning"  of,  10 
red  cells  of,  4 
serum  of,  4 
transfusions  of,   15 
vessels,    instruments    and    sutures 

for,   305 
white  cells  of,  4,  10 
Board  arm,   283,   413 
Boeckman  method  of  catgut  sterili- 
zation,  258 
Boiling,    sterilization   by,    236,    237, 
246,  248,  250,  251,  252,  258,  259, 
260,  261,  286,  315,  330,  332,  333, 
348,  403_,  406,  407 
Bones,  grafting  of,  100 

instruments    and    sutures    for,    40, 

80,  82,  85,  100,  103,  306 
Lane  plates  for,   100,  307 
surgery  of,  87-104 
Book,  needle,   252 

suture,   298 
Bottles,  hot  water,  213,  220 
Box,  dressing,  202,  314 
Brain,  instruments  and  sutures  for, 
80,  82,  306 
surgery   of,    80-85 
Breast,  bandage  for,  385,  389 
draping  of,  282 
instruments-  and  sutures  for,   141, 

308 
operative  position  for,  140,  280 
surgery  of,   138-141 
Brewer  tube,  126 
Bronze  wire,  229,  230,  261,  307 
Brushes,  nail,  212,  215,  236,  263 
Buck's  extension,  94 
Burmeister   method   of    catgut   ster- 
ilization, 258 
"Burns,  135-138 
Button,  Murphy,  54,  302,  '303 

Calcium  lactate,  36,  79 
Calculus,  of  bladder,  145 

renal,  144 
Callus  formation,  88 
Canton  flannel  bandage,  359,  360 
Canula,  Hahn's,  124 
Capeline  bandage,  383 
Capillary  bleeding,   17,   18 
Caps,  operating  room,  212    215    247, 

400 
Carbolic  acid,  57,  111,  246,  248,  251, 

254,  409 
Carbon  monoxide  poisoning,  136 
Carcinoma,  of  breast,  140 
pf  esophagus,   45 


Carcinoma,  of  jaw,  40 

of  larynx,  124 

of  ovary,  115 

of  pancreas,  68 

of  prostate,  119 

of  rectum,  64 

of  stomach,  53 

of  uterus,  112 
Care  of  patient,  in  anesthesia,   175, 

180 
Carpets,  in  home  operations,  404 
Carrel,  Dr.  Alexis,  323 
Carrel-Dakin  treatment,  321-354 

adjustment  of  appliances  for,  340 

bacteriological  examination  of 
wound  in,  345 

continuous  method  of,  342,  344 

debridement  in,  334 

definition  of,  321 

dressing  of  wound  in,  335 

dressings  for,  326,  330,  331,  338 

equipment  for,  215,  324 

history  of,  323 

instillation  of  solution  in,  342 

instruments  for,  324,  328 

intermittent   method  of,   341,   344 

reservoir  method  of,  341,  342,  344 

suturing  of  wound  in,  347 

syringe  method  of,  342,  344 

tubes  for,  325,  329,  336,  347 
Carriage,  dressing,  316 
Casts,  plaster  of  Paris,  91,  93,  390, 

397 
Catgut,   chromic,    228,    258 

method  of  rolling,  255 

plain,  228,  254-258 

sterilization  of,   254-259 
Cathartic,   before   operation,   58,   62, 

174 
Catheterization,  82,   105,  106,   175 
Catheters,  212,  216 
Cautery,  212,  216,  236,  242,  243,  244 

uses  of,  18,  57,  63,  242,  300 
Celiotomy,  48,  55 
Cells,  red  blood,   4 

white  blood,  4,  10 
Celluloid  linen   thread,   229 
Centigrade  thermometer  scale,  430 
Cerebrospinal  system,  80 
Cervix,  instruments  and  sutures  for, 
308 

surgery  of,  108 
Chair,  use  of  for  Trendelenburg  po- 
sition, 410 
Chamber,  Sauerbruch,   129 
Chemical  sterilization,  235,  236,  245, 

see  also  alcohol,  bichloride  of 
mercury,  carbolic  acid,  Dakin's 
solution,  ether,  formalin,  iodine, 
lysol 


440 


INDEX 


Chest,  bandage  for,  388,  389 

instruments  for,  309 

operative  position  and  draping  for, 
27S 
Cheyne-Stokcs  respirations,  81 
Chiil,  187 

Chin  bandage,  381,  382,  389 
Chlorinated  lime,  titration  of,  351 
Chkiroforni,   anesthesia,  care   of   pa- 
tient in,   179,  189 

decomposition  of,  204,  408 
Choked  itise,  81 
Chok^cystectomy,  66 
Cholecystenterostomy,   67 
Cholecystostomy,    (56 
Chok'cystotomy,  66 
Clioledochotomy,  66 
Chok^gastrostomy,  67 
Chok^lithiasis,  65-67 
Chromic  catgut,  228,  258 
Cigarette  drain,  310 
Circular  mode  of  bandaging,  366 
Circumcision,   150 
Cirrhosis  of  liver,  68 
Citrate  of  sodium,   16 
Clamp,  crushing,  297,  300 

intestinal,  302 

stomach,   50,  305 

tongue,  185,  213,  231 

towel,    270,    272,    278,    279,    281, 
285,  287,  288,  290 
Clamp  and  cautery  operation,  63 
Claudius  method  of  catgut  steriliza- 
tion, 257 
Cleaning,  of  Carrel-Dakin  tubes,  347 

of  gloves,  294 

of  home  operating  room,  404 

of  instruments,  293 

of  operating  table,   292 
Clips,  Gushing,   82 

metal  skin,  229,  230,  261 
Clot,  blood,   4,   35 
Clothing  for  anesthesia,  28,  175 
Clotting  time  of  blood,  36 
Clover  crutch,  412 
' '  Cock-up  ' '  wrist  splint,  100 
Colectomy,  60 
Collapse,"  190 
Colon,  irrigation  of,  25 

surgery  of,  60 
Colostomy,  60 

bag  for,  61 
Colpotomy,   112 

Complications,  after  anesthesia,  180, 
182,  184,  186,  187,  188,  189,  190, 
191 

post-operative,    20-37,    51,    59,    63, 
67,  75,  78,  79,  103,  114 
Compound  fracture,  87 
Compression  of  brain,  81 


Concussion   of   brain,    81 
Congenital,   deformities,    13 

hei'uia,  7(1 
Connecting  tubes,  327,   333 
Construction,  of  anesthetizing  room, 
204 

of  dressing  rooms,  206 

of  operating  room,  195 

of  sterilizing  room,  209 

of  work  room,  208 
Continuous    method   of   Carrel-Dakin 

treatment,    342,    344 
Contracture  of  esophagus,  45 
Contusion,    130 
Cord,  spinal,   85 
Cotton,  212,  216,  247 

gloves,  213,  219 

pads,  326,   331,   338 
Count,   bacteriological,   345 
Cover,  glove,  213,  218 

instrument  stand,  212,  216 

muslin,  for  parcels,  203,  247,  313 
"Crab"    wrist   splint,    100 
Craniotomy,   80,  82,   83,   84 
Crepe  paper  bandage,  360,  361 
Cretinism,    73 
Crile,  Dr.  George  W.,  75 
Crutches,  104 

lithotomy,  411 
Culture  tubes,  213,  217 
Cultures,  of  Carrel-Dakin  wound,  345 
Curettage  of  uterus,  108 

instruments  for,  308 
Gushing,  clips,  82 

suture,   50 
Cutting  down  of  plaster  cast,  397 
Cyst,  40,  114 

ovarian,  instruments  for,  308 
Cystadenoma  of  ovary,  114 
Cystitis,   146 
Cystocele,  105 
Cystoscope,  143,   149 

Dakin,  Dr.,  324 

Dakin   solution,   215,   246,   324,   325, 
328,  331,  332,  347,  348-354 

action   of,   349 

composition  of,  348,  351 

Daufresne's  technic  for,  350 

definition  of,  348,  350 

dosage  of,  343 

instillation  of,   342 

making  of,  350-354 

table  of  quantities  of  ingredients 
of,  352 

titration   of,   353 
Dam,  rubber,  213,  225,  249 

drains  of,  310 
Dauf resne  's  technic,  350 
Debridement,  334 


INDEX 


441 


Decapsulation,  Edebohl's,  34 
Decompression  of  brain,  85 
Defibrinated   blood,    17 
Deformities,  13 

Delivery  tubes,   Carrel-Dakin,   clean- 
ing of,  347 

making  of,  329 

rubber  for,  325,  329 

uses  of,  336 
Demarcation,  line  of,  10 
Depression,   of  pulse,   179,   187,   190 

respiratory,   184 
Dermoid  cyst  of  ovary,  114 
Deviated  septum,   120 
Diabetic  diet,   155 
Dichloramine-T,  349 
Diet,  after  anesthesia,  152,  182,  188, 
190,   191 

anti-constipation,   169 

anti-obesity,  171 

before  anesthesia,  174 

diabetic,   155 

gastric,   160 

general  rules  for,  170 

Lenhartz,  162 

liquid,  151 

nephritic,  159 

regular,  154 

salt-poor,  159 

soft,   152 

standard  strict,  156 

Von  Leube,  161 
Dietetics,  surgical,   151-172 
Dilatation,  of  cervix,  108,  308 

of  esophagus,  45 

of  sphincter  ani,  63 
instruments  for,  305 

of  stomach,  22 
Direct  hernia,  69 
Discipline  of   operating   room  staff, 

194,  212 
Disinfectant,  definition  of,  233 
Disinfection,   of   floor,   293 

of  linen,  293 
Distention,  abdominal,  23 
Distributing      tubes,      Carrel-Dakin, 

327,  333 
Dorsal  position,  267 
Double  roller  bandage,  382 
Douche  bag  as  irrigator,  332,  406 
Drainage    of    wounds,    siphon    and 

suction,   132 
Drains,  55,  113,  126,  249,  250,  310 
Dram,  fluid,  table  of  drops  in,  425 
Draping,  arm  position,  282,  283 

breast  position,  282 

dorsal  position,  268 

face  position,  287 

foot  position,  285,  286 

for  home  operations,  409 


Draping,  gall   bladder   position,   275 

hand   position,   282,   284 

head  position,  287,   288,  290 

kidney  position,   275 

latero-prone  position,  278 

leg  position,  285 

lithotomy  position,  280 

neck  position,   288 

nose  position,  288 

of  tables,  264 

prone  position,   276 

reversed    Trendelenburg    position, 
279 

Sims  position,  279 

skull  position,  288 

throat  position,  288 

Trendelenburg  position,  273 
Dresser,  as  supply  table,  404 
Dressing  of  the  vpound,  313-320 

Carrel-Dakin  method  of,  335 

dressing  box  for,  314 

dressing  carriage  for,  316 

instruments  for,  315,  318,  324,  328, 
335 

preparation  of  supplies  for,  313 

sterilizer,  instrument,   for,   315 
Dressing  room,  195,  206,  207 
Dressings,  wound,  213,  217,  247,  330, 
331,  338,  400 

carriage  for,  316 

drums  for,  202,  206,  207,  246,  314 

handling   of,    246,   291,    314,   318, 
319,  335 

instruments  for,  297,  311,  315,  318, 
324,  328,  335 

packing  of,  246,  313 

portable  stand  for,  290 

sterilizers  for,  209,  237-241,  401 

strapping  device  for,  317 

wet,  132 
Drop,  relation,  of  to  minim,  425 
Dropper  tube,  327,  333,  342 
Drugs,  list  of,  217 
Drums,  dressing,  202,  206,  207,  246, 

314 
Dry  heat,  as  wound  treatment,  133 

sterilization  by,  236,  241,  252,  254, 
256,  257,  258,  402 
Drying   of    sterilized    supplies,    241, 

402 
Ducts,  bile,  65 
Duodena  1  ulcer,  53 
Durability  of  bandages,  363,  364 
Dwarfism,  73 

Dyeing  of  suture  materials,  260 
Dysmenorrhea,  109' 

Ear  bandage,  380 
Ectopic  pregnancy,  113 
Edebohl's  decapsulation,  34 


442 


INDEX 


Edema,  of  glottis,  78 
pulnionarv,  80,   187 
Elastic  bandages,  252,  360,  390 
Elbow  bandage,  375 
Electric,  cautery,  243 

]iortal)le  iiistnuuent  sterilizer,  315 
Embolism,  pulmonary,  30 
Embolus,  31 
Empyema,  125 

Brewer  drainage  tube  for,  126 
instruments  for,  309 
Enemas,  24,  58,  62,  172,  175 
Enterostomy,  55 
Epididymis,   115 
Epulis,  40 

Equipment,    for    Carrel-Dakin    treat- 
ment, 215,  324 
of  operating  theater,  193-231 
Equivalent,  measures,  429 
temperature  scales,  430 
weights,  427 
Esmareh  bandage,  102,  212,  252,  360, 

390 
Esophagotomy,  46 
Esophagus,  surgery  of,  45 
Ether,  anesthesia,  care  of  patient  in, 
178,  183 

pneumonia  after,   27,   186,   187 
as   antiseptic,    74,    105,    117,    140, 

246,  258,  266 
inhaler  for,  213,  220 
Ethyl    chloride    anesthesia,    care    of 

patient  in,  179,  190 
Evacuator,  Bigelow,  148 
Evenness    of   pressure   in    bandages, 

363 
Evisceration,  30 

Examination,  bacteriological,  of  Car- 
rel-Dakin wound,  345 
Excitement,  control  of  in  anesthesia, 
176,  177,  178,  179,  183,  189,  190 
Exercises,  setting-up,  170 
Exophthalmic  goiter,  75 
Exploratory  laparotomy,  53 
Exploring  needles,  213,  223 
Extension,  Buck's,  94 
Eyes,  bandage  for,  378 

protection  of  in  vomfting,  186 

Face,  bandage  for,  381 
draping  for,   287 
guards  for,  283,  288,  290 
masks  for,  213,  221,  247,  400 
operative  positions  for,  286 
Fahrenheit  thermometer,  x,  430 
Fallopian  tubes,  surgery  of,  112 
Fallopius,  X 

Fascia,  sutures  for,  300,  301 
Fastening  of  bandages,  392 
I'at  layer,  sutures  for,  300,  301 


Fecal  fistula,  60 
Feeding  through  fistula,  172 
Femoral  hernia,   70 
Fibrin  strands,  4 
Fibroadenoma   of  breast,   140 
I'^ibroblasts,   4 
Fibroids  of   uterus,  111 
Field,  operative,  preparation  of,  70, 
74,   82,   83,   102,   105,   117,   140, 
174,  265,  407 

surgical,   8 
Figure-of-8  mode  of  bandaging,  370 
Finger  bandage,  373 
Fistula,  fecal,  60 

feeding  through,  172 

gastric,  46 

in  ano,  62 
Fixation  of  uterus,  110 

sutures  for,  308 
Flame,    sterilization    by,    236,    242, 

406 
Flannel  bandage,  212,  360 
Floor,  basins  for,  214 

benches,  200 

construction  of  in  operating  room, 
196,  204,  209 

disinfection  of,  293 
Florence  Nightingale,  xiii 
"Fluffs,"'  217 

Food,  after  anesthesia,  152,  182,  188, 
190,  191 

before  anesthesia,  174 
Foot,  bandage  for,  376,  377,  388 

draping  of,  285,  286 

operative  positions  for,  284 
Forceps,  dressing,  297,  311,  324,  328, 
335 

tongue,   185,  213,  231 

towel,  270,  272,  278,  279,  281,  285, 
287,  288,  290 
Foreign  bodies,  in  esophagus,  45 

in  larynx,  121 

in  lungs,  129 

in  trachea,  45 
Formalin,  246,  293,  409 
Forms  of  bandages,  356 
Formula3  for  preparation  of  catgut, 

256-259 
Fowler's  position,  59 
Fractional  sterilization,   249 
Fractions,  reckoning  of  solutions  in, 

420 
Fractures,  80,  87-102 

compound,  87 

definition  of,  87 

immobilization  of,  88 

impacted,  87 

of  the   skull,  80 

open  operations  for,  100 

reduction  of,  88,  100 


INDEX 


443 


Fractures,  simple,  87 

traction  treatment  of,  94-100 
Frame,  Balkan,  98 
Furniture,    for    anesthetizing    room, 
205 

for  dressing  room,  206 

for  operating  room,  197 

for  sterilizing  room,  209 

for  work  room,  208 

Gags,  mouth,  185,  213,  222 

Galen,  ix 

Gall  bladder,  draping  for,  275 

instruments  and  sutures  for,  304 

operative    positions   for,    273,    411 

surgery  of,  65-67 
Gallstones,  65 
Gases,  from  decomposed  chloroform, 

204,  408 
Gastrectomy,  53 
Gastric,  diet,  160 

dilatation,  22 

fistula,  46 

ulcer,  48,  52 
Gastroenterostomy,   49 
Gastrojejunostomy,  49 
Gastrostomy,  46 
Gatch  bed,  29 
Gauntlets,  213,  218,  247 
Gauze,  213,  218,  246 

bandages,  212,  359,  360 

packing,  213,  223,  247,  311 

vaselinated,  325,  328,  335 
Generation,  organs  of,  105 
Germicide,   definition   of,   233 
Gigantism,  73 
Gilliam  operation,   110 
Gland,    or    glands,    classification    of, 
72 

instruments  and  sutures  for,  305, 
306 

of  internal  secretion,  72 

parathyroid,   79 

pituitary,   73 

prostate,  117 

thyroid,  surgery  of,  73-79 
Glandular  system,  72-79 
Glassware,,  sterilization  of,  263 
Glossectomy,  41 
Glottis,  edema  of,  78 
Glove  cover,  213,  218 
Gloves,  cotton,  213,  219 

rubber,  213,  218 
cleaning  of,  294 
patching  of,  294 
preparation  of  for  sterilization, 

247 
sterilization  of,  248,  400,  407 
Glue,  resin  and  turpentine,  98 

Sinclair's,  98 


Glycerin,   252 

Goiter,  exophthalmic,  75 

instruments   and   sutures   for,    74, 

306 
operative     position     and     draping 

for,  288 
surgery  of,   74-79 
Gowns,    operating    room,    213,    220, 

247,  400 
Grafts,  bone,  100 
skin,   134 

instruments  for,  134,  309 
Granulation  tissue,  4,  134 
Grouping   of  blood  for  transfusion, 

15 
Growths,   new,    13,   40,   41,   46,   114, 

117,  124,  140,  148 
Guards,  face,  283,  288,  290 
Kocher,  283,  288 
shoulder,  271,  273 

Hahn  's  canula,  124 
Handling,    of    anesthetized    patient, 
180 
of   sterile  supplies,  246,  291,  314, 
318,  319,  335 
Hands,  bandages  for,  373,  375,  388 
draping  for,  282,  284 
methods  of  fastening  in  operative 
positions,  177,  268,  273,  275,  278, 
280,  282,  288 
operative  position  for,  283 
sterilization  of,  263,  319,  408 
Harvey,  ix 
Hawley  table,  93 

Head,  bandages  for,   366,   372,   382, 
388,  389 
control  of  in  anesthesia,  29,  184, 

186 
draping  of,  287,  288,  290 
operative  positions   for,   276,   286, 

287,  288 
rest  for,  288 
Headache,  182,  191 
Healing  of  wounds,  4,  134 
Heat,  dry,  as  wound  treatment,  133 
sterilization-  by,    236,    241,   252, 
254,  256,  257,  258,  402 
moist,  236,  237 
Heating   of    operating   theater,    197, 

205,  208,  209 
Heel  bandage,  377 
Heniatemesis,  48 
Hemophilia,  36 
Hemorrhage,  17-19,  59,  103 

and  shock,  14-19 
Hemorrhoids,  63 

Hernia,  instruments  and  sutures  for, 
70,  304 
surgery  of,  69-71 


444 


INDEX 


Hiccough,  after  anesthesia,  187,  190 
Highnune,  aLtrum  of,  121 
Uilipofiates,  ix 
Hips,  bandages  for,  387,  388 

rests  for,  213,  220,  3S8 
History,  of  Carrel-Dakin  treatment, 
323 

of  surgery,  ix-xv 
Hodgen's  splint,  94,  96,  100 
Home,  operations  in,  399-414 
Horsehair,  229,  259 

drains  of,  310 
Horse  serum,  36 
Horsley's  wax,    18 
Hot   air,  sterilization   by,   236,   241, 
252,  254,  256,  257,  258,  402 

sterilizer,  241 
Hot  towel  drum  and  heater,  202 
Hot  water  bottles,  213,  220 
Hunter,  Dr.  John,  x 
Hydrocele,   116 

Hydrochloric  acid  gas,  204,  408 
Hydrosalpinx,   113 
Hyperpituitarism,  73 
Hyper  thy  roidisir.,   73 
Hypertrophy,  of  tonsils,  44 

of  turbinates,  121 
Hypodermic  needles,  213,  223,  252 
Hypodermoclysis,  indications  for,  15 

outfit  for,  213,  220 
H;j7)opituitarism,   73 
Hypothyroidism,  73 
Hysterectomy,  110,  111,  112 

instruments  and  sutures  for,  111, 
307,  308 

Ice  pack,  75,  78 
Ileus,  paralytic,  26 
Immobilization  of  fractures,  88 
Impacted  fractures,  87 
Improvised    operative    position,    for 
arm,  413 

for  gall  bladder,   411 

for-  kidney,  411 

lithotomy,  411 

Trendelenburg,  410 
Incarcerated  hernia,  69,  71 
Indirect  hernia,  69 
Infected  wounds,  7,  132 
Infection,  definition  of,  232 

of  wound,  3,  7,  132 
Inflammation,  3 
Infusion,   indications  for,   15 

outfit  for,  213,  220 

salt  solution  for,  213,  226,  249 
Inguinal  hernia,  69 
Inhaler,  ether,  213,  220 
Injuries,  3,  13 

of  brain,  81 

of  liver,  67 


Injuries,  tif  thoracic  wall,   125 

of  urinary  bladder,  145 
Instillation  of  Dakin's  solution,  335, 
342 
adjustment  of  appliances  for,  340 
Instrument  stand  cover,  212,  216 
Instruments,  213,  220 

arrangement  of  on  stand,  298 

cleaning   of,   293 

for    Carrel-Dakin    dressings,    324, 

328 
for  dressings,  297,  311,  315,  318, 

324,  328,  335 
for  operations,  40,  44,  45,  46,  50, 
54,   57,   63,   70,   74,   80,   82,   85, 
103,    111,    122,    124,    134,    141, 
145,  148,  150,  297-310 
passing  of,  296-312 
sterilization  of,  246,  252 
sterilizers  for,  203,  315 
tables  for,  198,  405 
Intention,    primary    and    secondary, 

healing  by,  4 
Intermittent     method     for     Carrel- 
Dakin  treatment,  341,  344 
Internal  secretion,  glands  of,  72 
Intestines,  anastomosis  of,  53 
clamp  for,  302 
instruments   and   sutures   for,    54, 

57,  302 
obstruction  of,  55 
operative  position  and  draping  for, 

267 
perforation  of,  53,  59 
resection  of,  53,  55,  71 
surgery  of,  53-60 
Intratracheal  anesthesia,  41 
Intussusception,  56 
Iodine,   70,   82,   111,   246,   257,   258, 

266,  407 
Ironing  board,  as  instrument  table, 

405 
Irreducible  hernia,  69 
Irrigation  of  colon,  25 
Irrigators,   213,   221,   246,   326,   331, 
341 
douche  bag  as,  332,  406 
stands  for,  213,  221,  326,  331 
Ischiorectal  abscess,  61 
Isotonic,  as  property  of  Dakin's  so- 
lution, 349 
definition  of,  323 

Jacket,  plaster  of  Paris,  93 
Jackson  laryngoscope,  121 
Jaundice,  36,  65,  66 
Jaw,  bandage  of,  381,  382,  389 

holding  of  in  anesthesia,  29,  184 

surgery  of,  40,  41 
Jones 's  ' '  Crab ' '  wrist  splint,  100 


INDEX 


445 


Kangaroo  tendon,  228,  229,  259 
Kelly  pad,  213,  221 

improvised,  412 

uses  of,  280 
Kidney,  decapsulation  of,  34 

disorders  of  after  anesthesia,  187, 
190 

draping  for,  275 

instruments  and  sutures  for,   145, 
309 

operative  position  for,  275j  411 

surgery  of,  142-145 
Killian  laryngoscope,  121 
Kitchen,    as   home    operating    room, 

403 
Knee  bandage,  378 
Kocher  guard,  283,  288 
Kraske  operation,  64 


Lacerated  wounds,  131 
Lacerations,  130 
Laminectomy,  85 
Lane,  bone  plates,  100 

instruments  for  applying,  307 

technic,  100,  307 
Laparotomy,  exploratory,  53 

sheet,  213,  227 

draping  with,  268,  283 
Laryngectomy,  124 
Laryngoscope,  121 
Larynx,  surgery  of,   121-125 
Latero-prone  position,  278 
Lee  method   of   catgut   sterilization, 

256 
Legs,   bandages   for,   376,   377,   378, 
389 

draping  for,  285 

operative  positions  for,  284 

restraint    of    in    anesthesia,    177, 
183 

supports  for,  279,  284,  286,  411 

Thomas  splint  for,  100 
Lenhartz  diet,  162 
Lewisohn  transfusion,  16 
Lifting  of  anesthetized  patient,  180 
Ligation,  18 
Ligatures,  298,  302 
Light,  as  sterilizing  agent,  236 

for  operating  room,  195,  201,  403, 
406 
Lime,  chloride  of,  titration  of,  351 
Lindeman  transfusion,  16 
Line  of  demarcation,  10 
Linen,  disinfection  of,  293 

thread,  229,  260 
Liquid  diet,  151 
Lister,  xi-xiv,  235 

tourniquet  of,  102 
Litholapaxy,  148 


Lithotomy,  crutches,  411 

position,  279,  411 
draping  for,  280 

stirrups,  279,  284,  286,  411 

stockings,  213,  227,  247 
draping  with,  280 

suprapubic,  148 

towel,  213,  231,  247 
draping  with,  280 
Liver,  bile  ducts  and,  65 

surgery  of,  65-68 
Location  of  operating  room,  195 
Lockers,  dressing  room,  207 
Lungs,  edema  of,  30,  187 

embolism  of,  30 

instruments  and  sutures  for,  309 

surgery  of,  128-129 

tuberculosis  of,  129 
Lymph  glands,  instruments  and  su- 
tures for,  305 
Lymphadenitis,  12 
Lymphangitis,  12 
Lysol,  246,  248 

Malignant  growths,  13 
Malpositions  of  uterus,  109 
Management,  nursing,  between  oper- 
ations, 291 

of  operations,  290 
Many-tailed  bandages,  358,  362,  363, 

389 
Masks,    chloroform    and    ether,    213, 
221 

face,  213,  221,  247,  400 
Massage,  86,  89,  92,  102 
Mastitis,  138 

Mastoid  bone,  instruments  for,  309 
Mastoiditis,  83 

Materials  used  for  bandages,  359 
Mayo  cautery,  243 
Measures,  equivalent,  429 

tables  of,  428 

weights  and,  426 
Mending  of  gloves,  294 
Mental   preparation    of    patient   for 

operation,  76,  173 
Metal  clips,  229,  230,  261 
Meteorism,  23 
Metric,  measure,  428 

weight,  426 
Michel  clips,  230 
Mikulicz  drain,  310 
Minim,  relation  of  to  drop,  425 
Modes  of   applying  the  roller  band- 
age, 365 
Moist  heat,  236,  237 
Mortification,  10 
Moulded  plaster  splints,  92 
Mouth,  care  of,  39,  41,  42,  186,  189 

gags  for,  185,  213,  222 


446 


INDEX 


Mouth,  operative  position  am]  diap- 
inj?  for,  286 

surgery  of,  39 

wash  for,  39,  189 
Movements,  passive,  89 
Murphv  button,  54,  302,  303 
Muscle,  sutures  for,  298,  301 
Muslin,  apron,  212,  214,  247 

bandage,  212,  360 

covers  for  parcels,  203,  247,  313 

sheets,  213,  227,  247 

sterilization  of,  246 
^Myomectomy,  111 
Myringotomy,  83 
Myxedema,  74 


Nail,  brushes,  212,  215,  236,  263 

cleaners,  213,  223 
Nausea,  20,  182,  185,  188,  189,  191 
Neatness  of  bandages,  363,  364 
Neck,  operative  positions  and  drap- 
ing for,  288 
Needle  book,  252 
Needles,  exploring,  213,  223 
hypodermic,  213,  223 
sterilization  of,  252 
suture,  213,  223 

kinds  for   operations,   297,   298, 
300,   301,  303,  304,   305,   306, 
307,  308,  309 
Negative  pressure,  129 
Nephrectomy,  144 
Nephritic  diet,  159 
Nephrolithotomy,  144 
Nephrotomy,  143 

Nerves,  instruments  and  sutures  for, 
306 
spinal,  surgery  of,  85 
Nervous  system,  80-86 
Neuritis,  85 

New  growths,  classification  of,  13 
of  bladder,  148 
of  breast,  140 
of  esophagus,  46 
of  jaw,  40 
of  larynx,  124 
of  ovarv,  114 
of  testicle,  117 
of  tongue,  41 
New  York  Hospital  method  of  cat- 
gut sterilization,  258 
Newspapers,      in      home      operating 

room,  402,  404,  409,  413 
Nightingale,  Florence,  xiii 
Nitrous    oxide    anesthesia,    care    of 

patient  in,  178_,  182 
Nose,  operative  position  and  draping 
for,  288 
surgery  of,  120 


Nourishment,   after   anesthesia,    152, 
182,  188,  190,  191 
before  anesthesia,  174 

Novocain,  sterilization  of,  252 

Nurses,  division  of  duties  of,  211 
operating  room  duties  of,  290,  291 
operating  room  staff  of,  210,  291 
qualifications  of,   394,  2j0,  212 
training  of,  194,  212 

Nursing,  of  alimentary  system,  38-71 
of  glandular  sj'stom,  72-79 
of  nervous  system,  80-86 
of  osseous  system,  87-104 
of  reproductive  system,  105-119 
of   respiratory  system,   120-129 
of  skin  and  appendages,  130-141 
of  urinary  system,  142-150 

Nutrient  enema,  172 

Obstruction,  intestinal,  55 

respiratory,  181,  184,  189 
Olive  oil,  sterilization  of,  252 
Omentopexy,  68 
Oophorectomy,  115,  308 
Open  operations  for  fractures,  100 
Operating  room,  arrangement  of,  193 

bathroom  as,  403 

bedroom  as,  403 

construction  of,  195 

equipment  of,  193 

floors  of,  196 

furniture    for,    197 

in  action,  263-295 

kitchen  as,  403 

light  for,  195,  201,  403,  406 

location  of,  195 

nurses  of,  194,  210,  211,  212,  290, 
291 

organization  of,   193 

personnel  of,  194,  210,  212,  291 

preparation  of  for  operations,  263, 
408 

renovation  of  in  home,  404 

selection  of  in  the  home,  403 

size  of,  195 

sterilization  in,  232-262,  292,  295, 
409 

supplies  for,  212 

temperature  of,  197,  263 

walls  of,  196,  204 
Operating  tables,   197,  405 

cleaning  of,  292 
Operating  theater,  193-231 
Operations,   complications   after,  see 
complications. 

draping  for,  266 

dressings  for,  217,  400 

in  the  home,  399-414 

instruments  for,  see  instruments 

nurses'  duties  during,  290 


INDEX 


447 


Operations,  nurses'  management  be- 
tween, 291 
positions  for,  266,  410 
preparation,  of  operative  field  for, 
see  preparation. 
of  patient  for,  see  preparation 
of  room  for,  263,  408 
representative,       for       instrument 

passing,  297-310 
sutures  for,  see  sutures 
Operative,  field,  preparation  of,  see 
preparation 
positions  and  draping,  266-290 
improvised,  410-413 
Ophthalmoscope,  81 
Orderlies,  operating  room,  291 
Organization    of    operating    theater, 

193 
Osmotic  pressure,  322 
Osseous  system,  87-104 
Osteomyelitis,  101 
Ovaries,  cyst  of,  114 
•  instruments  for,  308 
surgery  of,  114-115 
Oven,  as  sterilizer,  241,  402 

Pack,  ice,  75,  78 

Packing,  gauze,  213,  223,  247,  311 

of  supplies,  246,  313 

of  the  wound,  133 
Pad,  or  pads,   abdominal,   213,   223, 
247 

Carrel-Dakin    dressing,    326,    331, 
338. 

Kelly,  213,  221 
improvised,  412 
uses  of,  280 

operating  table,  213,  224,  405 
Pagenstecher    linen    thread,    50,    57, 

229 
Pallor,  in  chloroform  anesthesia,  190 
Pancreas,     operative     position     and 
draping  for,  267 

surgery  of,  68 
Paper  bandage,  crepe,  360,  361 
Paquelin  cautery,  244 
Paracentesis,  abdominal,  68 
Paraffine,  for  burns,  137 

for  silk  thread,  229,  260 
Paralytic  ileus,  26 
Parasites,  12 
Parathyroid  gland,  79 
Passing  of  instruments,   296-312 
Passive  movements,  89 
Paste,  Beck's,  56 
Pasteur,  Louis,  xi 
Patching  of  gloves,  294 
Pathology,  3-13 
Paul's  tube,  55 
Pelvic  rest,  213,  220,  388 


Per  cent  of  solutions,  416 
I'erforated  gastric  ulcer,  49,  52 
Perforation,  in  appendicitis,  59 

intestinal,  53 
Perineorrhaphy,  105,  110 

nursing  care  of,  106 
Perineum,    instruments   and    sutures 
for,  308 

surgery  of,  105 
Peritoneum,  sutures  for,  298,  301 
Peritonitis,  59 
Peritonsillar  abscess,  43 
Pernicious  vomiting,  21 
Personnel    of    the    operating    room, 

194,  210,  212,  291 
Pessary,  109,  110 
Phagocytes,  10 
Pharynx,  surgery  of,  43 
Phimosis,  150 
Phlebitis,  35 
Phlebotomy,  34 
Phosgene  gas,  204,  408 
Piles,  63 
Pillows,  213,  225 

uses  of,   267,   273,   274,   276,   282, 
407,  410,  411,  413 
Pins,  Wyeth's,  103 
Pituitary  gland,  73 
Plaster  of  Paris  bandages,  applica- 
tion of,  91,  93,  390 

jacket  of,  93 

making  of,  361 

molded  splints  of,  92 

removal  of,  397 

spica  of,  93 
Plates,  Lane  bone,  100 

instruments  for  applying,  307 
Pneumonia,   "ether,"    186,   187 

post-operative,  27 
Poisoning,  blood,  10 

carbon  monoxide,   136 
Portable,  dressing  box,  314 

dressing  stand,  290 

electric  sterilizer,  315 
Portals  of  entry  for  bacteria,  12 
Position,  or  positions,  arm,  283,  413 

breast,  280 

dorsal,   267 

face,  286 

foot,  284 

for  genito-urinary  operations,   280 

for  gynecological  operations,   273, 
280 

Fowler's,  59 

gall  bladder,  273,  411 

hand,  283 

head,  276,  286,  288 

improvised  operative,  410-413 

kidney,  275,  411 

Kraske,  64 


448 


INDEX 


Position,   latero-prone,   278 

leg,  284 

lithotomy,  279,  411 

neck,  288 

operative,  and  draping,  266-290 

prone,  275 

reversed  Trendelenburg,  278 

Sims,  279 

skull,  288 

throat,  288 

Trendelenburg,  272,  410 
Positive  pressure,  129 
Post-oi)crative,      complications,      see 
complications 

hernia,  70 

pneumonia,  27 
Pregnancy,  ectopic,  113 
Preparation,  of  catgut,  254-259 

ot"  operating  room,  263,  408 

of  operative  field,  70,  74,  82,  83, 
102,  105,  117,  140,  174,  265, 
407 

of   patient  for   operation,   39,   55, 
58,  62,  66,  70,  74,  76,  118,  173 
Pressure,  bandage  for,  391,  392 

evenness  of  in  bandaging,  363 

negative  and  positive,  129 

osmotic,  322 

steam,  for  sterilization,  205,  237, 
239,  247,  248,  249,  251,  252,  328, 
331   332 

sterilizers,  205,  209,  237-241 
Primary  intention,  4 
Principles  of  bandaging,  363 
Problems,  solution,  418-424 

rules  for  solving,  418,  420 
Prolapse  of  uterus,  110 
Prone  position,  275 
Proportions,  algebraic,  418 
Prostate  gland,  surgery  of,  117-119 
Prostatectomy,   118 
Pulmonary,   complications   after   op- 
eration, 27-31,  187,   190 

edema,  30,  187 

embolism,  30 

tuberculosis,  129 
Pulse,  in  anesthesia,   177,   178,   179, 

180,  182,  187,  190,  191 
Punctured  wound,  130 
Purse  string,  52,  53,  57,  66,  298,  300. 
Pus,  10 

Pyelitis,  142,  143 
Pyemia,  10 

Pyonephrosis,  142,  143 
Pyosalpinx,  113 


Qualifications,  personal,  of  operating 

room  nurses,  194,  210,  212 
Quinsy  sore  throat,  43 


Radium  treatment,  43,  46,  111,  112, 

115,  119,  149 
Recovery  room,   195,  208 
Rectal  tube,  24,  213,  225 
Ixectocele,  105 

Eeetum,  instruments  and  sutures  for, 
63,  305 
operative    positions    and    draping 

for,  279,  280 
surgery  of,  61-65 
Eeeurrent  mode  of  bandaging,  372 
Eed  blood  cells,  4 
Reducible  hernia,  69 
Reduction  of  fractures,  88,  100 
Regular  diet,  154 
Removal,  of  adhesive  plaster,  317 

of  bandages,  396 
Renal  calculus,  144 
Renovation  of  home  operating  room, 

404 
Representative     operations    for     in- 
strument passing,  297-310 
Reproductive  sj'stem,   105-119 

instruments  and  sutures  for,  307 
Resection,  intestinal,  53,  55,  71 
rib,  126 

instruments  for,  309 
Reservoir    method    of    Carrel-Dakin 

treatment,  341,  342,  344 
Reservoirs    for    solutions,    326,    331, 

341 
Resin  and  turpentine  glue,  98 
Respirations,   after   anesthesia,    182, 
183,  189,  191 
Cheyne-Stokes,  81 
depression  of,  184 
Respiratory  system,  120-129 
Rest,  arm,  283,  413 
head,  288 

hip,  or  pelvic,  213,  220,  388 
operating  table,  274,  275 
Resterilization    of    operating    room, 

292,  295,  409 
Restraint   of   patient   in   anesthesia, 
176,    177,    178,    179,    183,    189, 
190 
Retention  of  urine,  31,  188 
Retractor,  amputation,  212,  213 
Retroversion  of  uterus,  109 
Reverdin  skin-grafts,  134 
Reverse  mode  of  bandaging,  368 
Reversed      Trendelenburg      position, 

278 
Rib  resection,  126 

instruments  for,  309 
Robb  leg  holder,  412 
Roller  bandage,   356,   359,  362,  365, 
373,  382 
modes  of  applying,  365 
Rolling  of  bandages,  356 


INDEX 


449 


Room,    operating,    arrangement    of, 

193 
construction  of,  195 
equipment  of,  193 
furniture  for,  197 
location  of,  195 
organization  of,  193 
preparation  of  for  operation,  263, 

408 
renovation  of  in  the  home,  404 
selection  of  in  the  home,  403 
sterilization  in,  232-262,  292,  295, 

409 
Eubber,  apron,  212,  214,  251 

bandage,  Esmarch,  102,  212,  252, 

360,  390 
bands,  213,  225,  247,  311 

as  drains,  311 

as  sleeve  holders,  225,  247 
dam,  213,  225 

drains  of,  310 

sterilization  of,  249 
gloves,  213,  218,  247,  248,  294,  400, 

407 
sheets,  213,  225 

uses  of,  267,  280,  282,  288,  412 
tissue,  213,  225 

drains  of,  310 

sterilization  of,  250 
tubing,  213,  225 

for  Carrel-Dakin  outfit,  327,  329, 
332 

for  drains,  310 

sterilization  of,  250 
Rules,  bandaging,  394 
for  diet,  170 
for  solving  solution  problems,  418, 

420 

Salpingectomy,  113 

instruments  and  sutures  for,  308 
Salpingitis,  112,  113 
Salt  solution,  213,  226 

preparation  of,  226,  405 

sterilization  of,  249,  405 
Salt-poor  diet,  159 
Sandbags,  213,  227 

uses  of,   267,   274,   275,   276,   278, 
280,    282,    284,    286,    288,    409, 
413 
Saprophytes,   12 
Sarcoma  of  jaw,  40 
Saturated  solution,  definition  of,  415 

making  of,  425 
Sauerbrueh  chamber,  129 
Scales,  equivalent  temperature,  430 
Scissors,  bandage,  319,  396,  397 

dressing,  318,  324,  328 
Scrubbing  of  hands,  263,  319,  408 
Scultetus  bandage,  358,  389 


Seat,  for  anesthetist  or  surgeon,  200, 

406 
^Secondary,  abscess,  59 

hemorrhage,  59,   103 

intention,  4 

suture,  134 
Secretions,  internal,  72 
Selection    of   home   operating   room, 

403 
Sepsis,  10,  232 
Septic,  definition  of,  232 
Septicemia,  10 
Septum,  deviated,  120 
Serum,  blood,  4 

horse,  36 
Setting-up  exercises,  170 
Shaving  of  operative  field,  40,  70,  74, 

82,  83,  102,  105,  140,  265 
Sheet,    or    sheets,    for    home    opera- 
tions, 400 

laparotomy,   213,   227 
draping  with,  268,  283 

plain  muslin,  213,  227,  247 

draping  with,  272,  279,  280,  282, 
284,  285,   287,  288,  290 

rubber,  213,  225 

uses  of,  267,  280,  282,  288,  412 
Shock,  81 

and  hemorrhage,  14-19 
Shoulder,  bandages  for,  384,  388 

guards  for,  271,  273 

spica  bandage  for,  384 
Silk  thread,  229 

sterilization  of,  260 
Silkworm  gut,  229,  230 

drains  of,  310 

sterilization  of,  260 
Silver  wire,  229,  230,  261,  307 
Sims  position,  279 
Sinclair's,  glue,  98 

skate,  96,  97 
Sinus  thrombosis,  83 
Sinusitis,  121 
Siphon  drainage,  132 
Sitz  bath,  63 
Size,  or  sizes,  of  bandages,  362 

of  operating  room,  195 
Skate,  Sinclair 's,  96,  97 
Skin,  and  appendanges,  130-141 

clips  for,  229,  230,  261 

grafts  of,  134 

instruments  for,  134,  309 

sutures  for,  300,  301 
Skull,  draping  of,  288 

fractures  of,  80 

instruments   and    sutures    for     80, 
82,  306 

operative  position  for,  2S6 
Skylight  in  operating  room,   195 
Sling,  388 


450 


INDEX 


Slough,  10 

Smears,    in   Carrel-Pakin    treatmoiit, 

345,  347 
Soda,    carbonate    of    as    sterilizing 
agent,  237,  252 
citrate  of" in  transfusions,  16 
Soft  diet,  152 

Soldering  iron  cautery,  Mayo,  243 
Solution,  Dakin's,  215,  246,  324,  325, 
328,  331,  332,  347,  348-354. 
action  of,  332,  343,  349 
composition  of,  348,  351 
Dauf rcsne  's  technic  for,  350 
definition  of,  348,  350 
dosage  of,  343 
instillation  of,  342 
making  of,  350-354 
table  of  quantities  of  ingredients 

of,  352 
titration  of,  353 
Solutions,  415-426 

algebraic     jiroportiou    method     of 

reckoning,  418 
antiseptic,  130,  245 
basins  for,  200,  212,  214,  246,  325, 

328,  406 
definition  of,  415 
fractional,  reckoning  of,  420 
indication  of  strengths  of,  416 
per    cent    method    of    reckoning, 

416 
problems  of,  418-424 

rules  for  solving,  418,  420 
salt,  213,  226,  249,  405 
saturated,  415,  425 
usual  strengths  of,  426 
Solvent  power  of  water,  415 
Sphincter  ani,  dilatation  of,  63^  305 
Spica  bandage,  93,  374,  384,  387 
Spinal  cord,  surgery  of,  85 
Spine,  instruments  and  sutures  for, 
85,  306 
operative     position     and     draping 
for,  276 
Spiral  mode  of  bandaging,  367 
Spleen,  instruments  and  sutures  for, 
306 
operative  position  and  draping  for, 
267 
Splint,  or  splints,  213,  227 
Hodgen  's,  94,  96,  100 
Jones's    "Crab"    or    "Cock-up" 

wrist,   100 
materials  for,  91 
plaster  of  Paris,  molded,  92 
sugar-tong,  92 
Thomas  traction,  100 
Sponges,  crauze,  217,  247,  330 
Spores,  killing  of,  237,  249,  259 
Sprains,  89 


Staff,  operating  room   nursing,   194, 

210,  212 
Stand,  dressing,  portable,  290 
instrument,   198,  405 

arrangement  of  instruments  on, 
298 
irrigator,  213,  221,  326,  331 
Standard  strict  diet,  156 
Starch  bandage,  212,  360,  390 
Stasis  of  colon,  60 
Steam,  in  operating  room,  204 
pressure   sterilizer,   205,   209,   237- 

241 
sterilization  by,  205,  236,  237,  247, 

248,  249,    251,    252,    328,    331, 
332,  401 

Stenosis,  cervical,  108 
Sterile    supplies,    handling    of,    246, 
291,  314,  318,  319,  335 

room  for,  195,  209 
Sterilization,   after    operations,    292, 
295,  409 

agents  of,  235 

between  operations,  292 

by  actual  cautery,  57,  242,  300 

by  boiling,  236,  237,  246,  248,  250, 
251,  252,  258,  259,  260,  261, 
286,  315,  330,  332,  333,  348,  403, 
406,  407 

by  chemicals,  235,  236,  245,  see 
also  alcohol,  bichloritle  of  mer- 
cury, carbolic  acid,  Dakin's  so- 
lution, ether,  formalin,  iodine, 
lysol 

by  dry  heat,  236,  241,  252,  254, 
256,  257,  258,  402 

by  flame,   242,   406 

by  steam,  205,  236,  237,  247,  248, 

249,  251,    252,    328,    331,    332, 
401 

definition  of,  234 

fractional,  249 

in  the  home,  400,   401,   402,   403, 

405,  406,  407,  408,  409,  410 
methods  of,  246 
of  catgut,  254-259 
of  gauze  and  muslin,  247 
of  gloves,  248,  400,  407 
of  hands,  263,  319,  408 
of  instruments,  246,  252 
of  operative  field,  70,  74,  82,  174, 

265,   407 
of  rubber  tissue,  250 
of  suture  materials,  254-262 
operating  room,  232-262 
temperatures   for,    236,    237,    239, 

241,  247,  248,  252,  256,  257,  258, 

402 
thermal,  235,  236 
vacuum  method  of,  240 


INDEX 


451 


Sterilizer,  hot  air,  241 

improvised,  for  home,  401 

instrument,  203,  315 

oven  as,  241,  402 

steam  pressure,   205,  209,  237-241 

test  for,  241 

utensil,  204 

vacuum,  240 

water,  204 
Sterilizing  room,  195,  209 
Stirrups,  279,  284,  286,  411 
Stockings,  for  traction,  96 

lithotomy,  213,  227,  247 
draping  with,  280 

ordinary,  for  draping,  286 
Stomach,  clamp  for,  50,  305 

dilatation  of,  22 

fistula  of,  46 

instruments   and   sutures   for,    50, 
305 

operative    position     and     draping 
for,  267 

surgery  of,  48-53 

tube  for,  213,  228 
Stone,  of  gall  bladder,  65 

of  kidney,  144 

of  urinary  bladder,  147 
Stopcocks,  327,  333,  341,  342 
Storage  room,  195,  209 
Strands,  fibrin,  4 
Strangulated  hernia,  69,  71 
Strapping,  device  for  dressings,  317 

for  fractures  and  sprains,  88,  89 
Strengths  of  solutions,  indication  of, 
416 

table  of,  426 
Stretchers,  198 
Stricture  of  esophagus,  45 
Struggling,  control  of  in  anesthesia, 
176,  177,  178,  179,  183,  189,  190 
Styptics,  19 
Suction   drainage,   132 
Sugar-tong  splint,  92 
Suits,  operating  room,  213,  228,  247 
Sunlight,  as  sterilizing  agent,  236 
Supplies,  for  Carrel-Dakin  treatment, 
215,  324 

for  dressings,  313 

for  operating  room,  212 

handling  of  sterile,  246,  291,  314, 
318,  319 
Supply  room,  sterile,   195,  209 
Suppression  of  urine,  32,  187,  188 
Suppuration,   10 
Suprapubic  lithotomy,  148 
Supravaginal  hysterectomy.  111 
Surgery,  history  of,  ix-xv 

of  alimentary  system,  38-71 

of  glandular  system,   72-79 

of  nervous  system,  80-86 


Surgery,   of   osseous   system,    87-104 
of  reproductive  system,  105-119 
of  respiratory  system,  120-129 
of  skin  and  appendages,  130-141 
of  urinary  system,  142-150 

Surgical  field,  3 

Suspension,  of  fractures,  98 
of  uterus,  110 

instruments  and  sutures  for,  308 

Suture,  or  sutures,  book  for,  298 
Gushing,  50 

for  operations,  42,  50,  57,  100,  297, 
298,  300,  301,  302,  303,  304,  305, 

306,  307,   308,  309,   310 
materials  for,  213,  228 

needles   for,    213,    223,    297,    298, 
300,    301,    303,    304,    305,    306, 

307,  308,  309 
secondary,  134 
sterilization  of,  254-262 
through-and-through,  230,  301 

Suturing  of  Carrel-Dakin  wound,  347 
Symbols,  abbreviations  and,  431 
Syringe     method     for     Carrel-Dakin 

treatment,  342,  344 
Syringes,  213,  230 

for    Carrel-Dakin    treatment,    326, 
332 

sterilization  of,  251 
System,  alimentary,  38-71 

glandular,   72-79 

nervous,  80-86 

osseous,   87-104 

reproductive,  105-119 

respiratory,  120-129 

skin  and  appendages,  130-141 

urinary,  142-150 

Table,  or  tables,  anesthetist's,  206 
draping  of,  264 
Hawley,  93 
instrument,   198,  405 

arrangement  of  for   operations, 
298 
operating,  197,  405 
supply,  198,  200,  206,  207,  404,  405 
Talma  operation,  68 
Teaching  of  nurses,   193,  194 
Technic,  definition  of,  234 
Lane,  100,  307 
of    dressing   the    wound,    313-320, 

335 
of   handling   sterile   supplies,   246, 

291,  314,  318,  319,  335 
of  unsterile  stage  in  operations,  50, 
57,  300,  303 
Temperature,    equivalent    scales    of, 
430 
operating  room,  197,  263 
standard,  of  water,  425 


452 


INDEX 


Temperature,    sterilizing,    236,    237, 
239,    241,    247,    248,    252,    256, 
257,    258,    402 
Tendons,    instruments    and    sutures 

for,  306 
Tension  of  bandages,  363 
Test,  for  alkalinity  of  Dakin's  solu- 
tion, 354 

for  sterilizer,  241 
Testicle,  surgery  of,  115 
Tetanus  spores,  259 
Tetany,  79 

Tlieater,   operating,    193-231 
Thermal  sterilization,  235,  236 
Thermo-eautcry,  236,  242 
Thermometers,  213,  231,   242,  255 

equivalent  scales  of,  430 

sterilization   of,   252 
Thiersch    skin-grafts,    134 
Thirst,  after  anesthesia,  20,  188,  189 
Thomas  traction  splints,  100 
Thoracic  wall,  surgery  of,   125 
Thread,  silk   ind  linen,  229,  260 
Throat,  operative  position  and  drap- 
ing for,  288 
Thrombosis,  35 

sinus,  83 
Througli-and-through      suture,      230, 

30 1 
Thumb,  spica  bandage  of,  374 
Thyroid  gland,  instruments  and   su- 
tures for,  306 

surgery  of,  73-79 
Thyroidism,  75 
Tissue,  granulation,  4,  134 

rubber,  213,  225 
drains  of,  310 
sterilization  of,  250 
Titration,  of  chloride  of  lime,  351 

of  Dakin  's  solution,  353 
Toe  bandage,  376 
Tongue,  control  of  in  anesthesia,  184 

forceps  for,  185,  213,  231 

surgery  of,  41-43 
Tonsillectomy,  44 

instruments  for,  44,  304 

operative  position  and  draping  for, 
286 
Tonsils,  surgery  of,  44 
Torsion,  18 

Tourniquets,   18,   102,  213,   231,  252 
Towels,  213,  231,  247 

clamps  for,  uses  of,  270,  272,  278, 
279,  281,  285,  287,  288,  290 

drum  for,  202 

for  home  operations,  400 

lithotomy,  213,  231,  247 
draping  with,  280 
Toxemia,  10 
Trachelorrhaphy,  109 


Tracheotomy,   74,  122 

Traction  treatment  of  fractures,  94- 

100 
Training  of  nurses,  193,  194 
Transfusions,   15-17 
Treatment,  Carrel-Dakin,  321-354 
Tremor,  after  anesthesia,  187 
Trendelenburg  position,  272,  410 
Trephine,  80,  82 
Triangular  bandage,  362,  388 
Truss,  70 
T-tube,  113 

Tub,  for  operating  room,  200 
Tube,  or  tubes.  Brewer,  126 

Carrel-Dakin,  325,  336 
cleaning  of,  347 
making  of,  329 
rubber  for,  325,  329 
uses  of,  336 

catgut,   261 

connecting,  327,  333 

culture,  213,  217 

delivery,    for    Carrel-Dakin    treat- 
ment, 325,  329,  336,  347 

distributing,      Carrel-Dakin,     327, 
333 

drainage,  310 

dropper,  327,  333,  342 

' '  en  chemise, ' '  64 

Fallopian,  surgery  of,  112 

Paul's,  55 

rectal,  24,  213,  225 

stomach,  213,  228 

T-,  113 
Tuberculosis,  of  epididymis,  116 

of  intestines,  53 

of  urinary  bladder,  147 

pulmonary,    129 
Tubing,   rubber,   213,   225 

drains  of,   310 

for  Carrel-Dakin  outfit,  327,  329, 
332 

sterilization  of,  250 
Tumors,   13 

of  brain,  84 

of  breast,  140 

of  jaw,  40 

of  uterus,  111 
Tunica  vaginalis,  116 
Turbinates,  hypertrophy  of,  121 
Tympanites,  23,  24 

Ulcer,  duodenal,  53 

esophageal,  45 

gastric,  48,  52 

intestinal,  53 
Umbilical  hernia,  70 
Unger   transfusion,   16 
Uremia,  33 
Ureters,  145 


INDEX 


453 


Urethra,  149 

Urethrotomy,  150 

Urinary,  bladder,  surgery  of,  145-149 
system,   142-150 

Urine,  albumen  in,   187,  190 
retention  of,  31,  188 
suppression  of,  32,  187,  188 
voiding  of,  31,  32,  188,  190 

Uses  of  bandages,  355 

Usual  strengths  of  solutions,  426 

Utensil  sterilizer,  204 

Uterus,  instruments  and  sutures  for, 
111,  307,  308 
operative    positions    and    draping 

for,  273 
surgery  of,   107-112. 

Vacuum,  sterilization  in,  240 
Vagina,  instruments  and  sutures  for, 
308 
operative     position     and     draping 

for,  280 
surgery  of,  105,  112 
Varicocele,  117 

Varicose  veins,  bandage  for,  391 
instruments  for,  305 
operative    positions    and    draping 
for,  284 
Vaselinated  gauze,  325,  328,  c25 
Vaseline,  sterilization  of,  252 
Veins,  instruments  for,  305 
Velpeau  bandage,  384 
Ventilation  of  operating  theater,  197, 

205,  208,  209 
Ventral,  fixation  of  uterus,  110. 

suspension  of  uterus,  110 
Vesalius,  x 

Voiding  of  urine,  31,  32,  188,  190 
Vomiting,   20,   21,   29,  52,   180,   181, 

182,   185,  188,   189,  191 
Von  Leube  diet,  161 

Walls,  operating  theater,  196,  204 
Wash,  basins,  206 

mouth,  39,  189 
Washing,  of  Carrel-Dakin  tubes,  347 

of  gloves,  294 

of  instruments,  293 


Washing,   of   operating  table,   292 

soda,  as  sterilizing  agent,  237,  252 
Water,  boiling,  236,  237 

for    anesthesia   patients,    20,    151, 

188,  189 
solvent  power  of,  415 
sterilization   of   in   the  home,   405 
sterilizers  for,  204 
table     of     standard    temperatures 
for,  425 
Wax,  Horsley's,  18 
Weights,    and    measures,    tables    of, 
426 
equivalent,    table    of,    427 
Wet  dressings,   132 
White  blood  cells,  4,   10 
Windows,  "frosting"  of,  405 
Wine  measure,  428 
Wipes,  gauze,  217,  247,  330 
Wire,    for   suturing,    100,   229,    230, 

261,  307 
Woie  skin-graft,  134 
Wood  splints,  91 
Work  room  for  nurses,  195,  208 
Wounds,    Carrel-Dakin,   bacteriologi- 
cal examination  of,  345 
dressing  of,  335 
suturing  of,  34V 
tubes  for,  325,  329,  336,  337 
types  of,  337 
classification     and     definition     of, 

130 
dressing  of,  313-320,  335 
dressings  for,  213,  217,   247,  330, 

331,  338,  400 
healing  of,  4,  134 
infected,   7,   132 
infection  of,  3 
lacerated,  131 
packing  of,   133 
punctured,   130 
suppurating,  10 
Wrist,   Jones  's   ' '  Crab  "   or   "  Cock- 
up"  splint  for,   100 
Wyeth's  pins,  103 

X-iaj  treatment,   43,    74^    111,   115, 
141 


COLUMBIA  UNIVERSITY  LIBRARY 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
,  expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

0 

(TT  1  1   rr 

■     ..r* 

■•' 

v' 

1 ,,  • 

'i  .■ 

u:-J^* 

^/5.y4    Y- 

C2e(23e)M100 

BD99 
Colp 


C71 


'"  COLUMBIA  UNIVERSlTniBRARIES  (tisl.stx) 

RD  99  C71  C.1 

Textbookolsiim|ca  iii";|i;a 


2002137232 


